Académique Documents
Professionnel Documents
Culture Documents
ACRONYMS
OVERVIEW OF FIGURES AND TABLES
PREFACE
PART I
HISTORY AS JUSTIFICATION
p12
p13
B.1
B.2
B.3
B.4
CONSEQUENCES OF VIOLENCE
C.1
Physical health
C.1.1
Increased physical complaints
C.1.2
Increased physical health disorders
C.1.3
Increased unhealthy behaviour
C.2
Mental health
C.2.1
Stress and distress
C.2.2
Acute psychiatric disorders
C.2.3
Post-Traumatic Stress Disorder (PTSD)
C.2.4
Other psychiatric co-morbidity
C.2.5
Depression
C.2.6
Generalised anxiety disorder
C.2.7
Chemical abuse/dependency
C.3
C.4
Children
C.4.1
C.4.2
C.4.3
C.4.4
C.4.5
C.4.6
p22
Justification
General reactions
Infants and toddlers
School children
Adolescents
Reactions within the family
D.2
Objectives
D.2.1
General objectives of mental health projects
D.2.2
General objectives of psychosocial projects
D.3
Package
D.3.1
D.3.2
D.3.3
PART II
E
p33
of psychosocial activities
Psycho logical package
Social package
Integration and comprehensive medical services
PROGRAMMING DETAILS
p40
E.1
E.2
E.3
Supportive counselling
E.3.1
Psychosocial support in the medical setting
E.3.2
Individual & group counselling
E.4
Children
E.4.1
Basic interventions
Acute emergencies
F.1.1
Practical support: provision of health care and basic materials
F.1.2
Information centre
F.1.3
Group debriefings
F.2
Chronic crises
F.2.1
Practical needs
F.2.2
Community mobilisation
F.2.2
Health education
F.3
F.4
Networking
Distraction activities
p52
INTEGRATION OF SERVICES
G.1
Justification
G.2
Medical staff
G.3
Integrated programming
G.3.1
G.3.2
G.3.2.1
G.3.2.2
G.3.3
G.3.4
G.3.4.1
G.3.4.1.1
G.3.4.1.2
G.3.4.2
G.3.4.3
G.3.4.3.1
G.3.4.3.2
G.3.4.3.3
G.3.4.3.4
G.3.4.4
G.3.4.5
G.3.5
G.3.5.1
G.3.5.2
G.3.5.3
G.3.6
G.3.6.1
G.3.6.2
G.3.6.3
ADVOCACY
PART III
p75
SPECIFIC TOPICS
FIELD ASSESSMENTS
I.1
Justification
I.2
Ethics
I.3
I.5
p78
I.4
p57
Early indicators
General needs assessment by the field team
In-depth assessments
I.5.1
Problem tree
PROJECT PLANNING
J.1
J.2
J.3
p102
K.1
K.2
Knowledge
Skills and attitude
Community exposure
K.4
K.5
Clinical supervision
Principles
Acute emergencies
L.2.1
L.2.2
L.2.3
L.3
Chronic crises
L.3.1
L.3.2
Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects
TRAINING
K.3
Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects
Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects
J.4
p89
Definitions
Output indicators
Process indicators
p106
p110
M.2
Job descriptions
M.3
Staff support
LOGISTICS
p112
DEFINITIONS
p113
p120
INDEX REFERENCES
p126
ACRONYMS
AIDS
ARV
Anti-Retroviral therapy
CBW
DSM
FGD
HIV
MHO
NGO
Non-Governmental Organisation
OPD
Outpatient department
PTSD
TB
Tuberculosis
VCT
Table 5
Table 6
Table 7
Table 8
Table 9
PART II
PROGRAMMING DETAILS
Table 12 Overview of acute crisis intervention strategies in MSF psychosocial, mental health projects
Table 13 Considerations for prescribing psychotropic drugs
Table 14 Summary of drugs and prescriptions in MSF psychosocial, mental health projects. ALWAYS read accompanying text above
Table 15 Overview of supportive counselling interventions in MSF psychosocial, mental health projects
Table 16 Overview of basic interventions in the management of traumatised children
Table 17 Overview of community mobilisation and health education
Table 18 Overview of social activities
Figure 7 Levels of psychosocial integration in basic health care programmes
Table 19 Overview of psychosocial activities in nutrition programmes
Table 20 Examples of possible psychosocial problems and interventions in TB Projects
Table 21 Overview of common mental health disorders associated with HIV/AIDS
Figure 8 Overview of the links between the tasks of (VCT) counsellors and other services
Table 22 Qualifications, roles and responsibilities of (VCT) counsellors
Table 23 Psychosocial support after sexual violence
Table 24 Neuropsychiatric syndromes or symptoms in biological agents
Table 25 Management and staff considerations for mental health interventions in populations affected by chemical and biological warfare
Table 26 General directions on advocacy in psychosocial/mental health programmes
PART III
SPECIFIC TOPICS
PREFACE
Mdecins Sans Frontires (MSF) started mental health and psychosocial interventions in 1990
with a community based programme in Gaza (Palestine). Since the early nineties MSF has
implemented psychosocial or mental health interventions in over 40 countries in nearly all
continents (except Australia).The interventions covered various aspects of mental health:
psychiatric patients in institutions, psychiatric care in acute emergencies, people suffering from
(acute) trauma, adaptation and chronic stress related psychological complaints, and
psychosocial support for individuals and groups to improve the efficacy of nutrition,TB and
HIV programmes.
As an emergency medical humanitarian organisation the bulk of our programming is in acute
or chronic settings of mass conflict. A situation of mass violence is characterized by events that
include a great number of people (thousands rather then hundreds) who have experienced,
witnessed or heard of traumatic events. Often there is significant material damage, destruction
of the social fabric and functioning of the community.
The Guidelines focus on man-made disasters rather than on natural disasters. It was not for
reasons of priority setting nor interest that this choice was made. We have gained more
experience in the field of man-made disasters. Despite the differences between these two
types of tragedies, our experiences in India and El Salvador (both earthquake interventions)
showed that the principles described in these Guidelines also work very well in contexts of
natural disasters.
Humanitarian workers have the moral obligation to share their technical experiences with
others to avoid repeating the same mistakes.These guidelines were written for this reason.
We do not claim that our intervention model is the only way to approach psychosocial or
mental health problems in areas of conflict. We realize the limitations and opportunities of
our organisations specific medical, humanitarian emergency origin as well as the specificity
of our experiences.
The manual is useful for people in co-ordinating positions (medical and programme
management) to strategize, to plan, to supervise, and to coach a psychosocial or mental health
programme component.
The manual is easily accessible for lay people and others interested in the theoretical
background and workings of conflict related psychological programme interventions.
Mental health professionals and medical staff with less experience in emergency psychosocial
programming may also profit from the manual in their preparation for field programmes.
The Guidelines are not intended to be a handbook for counselling or psychotherapy. It does not
contain detailed treatment protocols and specialised interventions because the mental health
specialist in the programme is supposed to have this knowledge and skills before departure.
Furthermore, cultural differences do not favour a standardised approach to protocols.
The set up of the guidelines helps people to find quick answers for their questions.Tables at
the end of each section summarize the most important issues. A table of contents including
an overview of tables and graphs are found at the start of the document.To improve
understanding a list of acronyms is available.
To augment understanding, technical specialist language is avoided as much as possible.
If special terminology is used a definition is available in one of the last chapters of the
guideline, see Chapter O.
Part II
PROGRAMMING DETAILS
The components of a psychosocial intervention: individual treatment and
group support are described in this section. MSF focuses its psychosocial
programmes on the general population.Therefore, the guidelines do not
contain a section on specific programmes for children.
Mental and physical health are regarded as inseparable. How to realise a
combined approach is dealt with in the chapter on integration. Examples are
given for nutrition, sexual violence, chemical and biological warfare. MSF also
deals with chronic diseases like tuberculosis and HIV/AIDS in areas of conflict.
The psychosocial support offered to people suffering from these chronic
disorders is included in the manual.
Health workers in settings of conflict bear witness to a lot of suffering. An
essential element of our mission is to speak out on what they see.
Opportunities for and limitations on advocacy are discussed in this part on
programming details.
Part III
SPECIFIC TOPICS
The guidelines finish with a detailed description of specific topics like
assessment, programme planning, monitoring/evaluation but also training and
human resource management.
To facilitate accessibility to these guidelines they are put on the MSF Holland website at
http://www.artsenzondergrenzen.nl
They are regularly updated to ensure adequate programming. Comments are welcome and
can be sent to Kaz.de.Jong@amsterdam.msf.org
The process of writing these guidelines has been lengthy because the support to people
implementing these programmes always prevailed and the growing number of programmes
made available time scarcer. Despite reflecting over ten years of field experience these
guidelines are only one step in the process of developing psychosocial and mental health
interventions in non-Western settings.The theoretical knowledge of trauma and experience in
programming is progressing rapidly.
Today there is more conflict than in any other time in history. At the same time we are
learning more about perspectives from other cultures. It is our duty to use the newly acquired
insights to increase understanding, to augment compassion and to reduce conflict.
10
PART I
GENERAL CONCEPTS
& PROGRAMMING
11
HISTORY AS JUSTIFICATION
Humans have experienced adverse psychological consequences from war throughout history.
A systematic study of the psychological effects of war began in the late nineteenth century.
However it was not until 1980 that a specific type of psychological suffering caused by mass
violence received official recognition. It was at this time that the internationally respected
Diagnostic and Statistical Manual of Mental Disorders III (DSM III) ascribed a unique psychiatric
diagnostic label to the phenomenon called Post-Traumatic Stress Disorder (PTSD).1
The creation of a new diagnostic label implied that a generalised pattern of reactions to
extreme events had been recognised. Under this new comprehension, psychological suffering
following traumatic experiences was no longer explained by an individuals weakness or
malingering,2 but by a series of predictable and measurable mental health and psychosocial
effects.
Since its acknowledgement, PTSD has become a popular area of psychiatric research. PTSD has
especially captivated researchers because it is considered one of the only psychiatric disorders
whose unique cause is an external event.3 In the decade following its discovery, research about
PTSD contributed significantly to Western researchers understandings about the relationship
between external stimuli and internal psychological processes.4 However, it also led to an
overemphasis on PTSD as the sole reaction to (mass) violence.
It was not until the mid 1990s that research interests surrounding the consequences of (mass)
violence broadened to include studies of how social, cultural, moral and spiritual environments
influence individual and group responses to trauma.
The following practical guidelines often refer to traumatic stress and PTSD. It must be noted,
however, that none of the contributors regards traumatic stress or PTSD as the sole reaction to
(mass) violence.The daily reality in the field of humanitarian assistance confronts us with the
pervasive destruction of all aspects of human health (physical, mental, social, spiritual and moral).
To save lives, and to improve the functionality and dignity of people who have experienced mass
violence, all these aspects need attention.The proposed intervention model is based on a
comprehensive view of human suffering after mass violence.
12
B
B.1
B1.1
Year
DSM III
1980
DSM III-R
1987
DSM IV (-TR)
1994
(2001)
Examples of
traumatic eventsi
(single/ accumulated)
Self experienced
Witnessed/heard
Getting wounded
Being threatened with death
Being subjected to gross human rights violations
Significant loss (of people or property)
Confrontation with actual fighting
(crossfire, bombardment, shelling)
Torture
Sexual violence
Killing (strangers or loved ones)
Dead bodies, mutilations, severely wounded
Stories of traumatic experiences
For the purpose of discussing the consequences of mass violence in the context of humanitarian
assistance, the definition of a traumatic event found in the DSM IV-TR (Diagnostic and Statistical
Manual of Mental Disorders IV Text Revised)12 will be used.
i This is just a selection and not intended to include all types of traumatic experience.
13
B.1.2
ii Several disciplines in mental health have emerged over the last few decades that take this into consideration including: cultural psychology, which has
as its basis the notion that no socio-cultural environment exists or has identity independent of the way human beings seize meanings from it; crosscultural psychology which focuses on performance differences between ethnic groups; psychological anthropology which examines psychological
functioning in socio-cultural contexts; ethno psychology which investigates indigenous or local conceptions of mind, self, body and person.
iii Transcultural psychiatry recognises three types of abnormal behaviour and cognition: those considered abnormal in the West, but normal in other
societies; those perceived as normal in the West, but abnormal elsewhere; and those that occur in exclusive socio-cultural environments (i.e. culturebound syndromes). By identifying a set of symptoms as being abnormal from a Western or non-Western perspective it is possible to ascribe an
accurate (Western) psychiatric label to non-Western expressions (symptoms) of illness.
iv Client refers to a beneficiary who has been admitted into a mental health or psychosocial programme to receive care, and is involved in a therapeutic
relationship with a counsellor/mental health practitioner. The client is not called patient (as in the medical setting) because psychosocial or mental
health support is not necessarily restricted to medical disorders.
14
MSF believes a combined mental health and psychosocial health care approach is necessary
to effectively assist survivors of trauma. By employing Western medical approaches to mental
health, as well as local definitions and perceptions of psychosocial health, MSF aims to restore
the functioning and dignity of survivors of traumatic experiences.
B.2
Fig. 1
Frightening,
overwhelming
Traumatic
event
Avoidance
Integration
Intrusion
Not coped
Processing
Disruption to
model of
the world
15
16
B.3
Fig. 2
Vulnerability
Event related (e.g. intensity, life danger, extent of physical injury,
number of experiences, duration, proximity, preparation)
Personal (pre-trauma coping style, psychiatric disorders)
Recovery environment (socio-economic, poverty, marginalisation)
Traumatic
event(s)
Avoidance
Integration
Coping process
Intrusion
Not coped
17
v In the manual the male form is used for reasons of convenience. Every male version used in relation to expatriates, national staff, clients or
beneficiaries can also be read as female.
18
Person related
Environment related
War wounded
Orphans
Physically disabled
Single mothers
B.4
Children alone
Widows
Fig. 3
Vulnerability
Resilience
Event related,
Personal,
Recovery environment
Traumatic
event(s)
Avoidance
Integration
Coping process
Intrusion
Not coped
19
B.4.1 Physical
Survivors of trauma often have many basic, practical problems.Those who have sufficient food
and water, good physical health and adequate housing have less stressors and are subsequently
in a more favourable position to cope with their psychological problems. It is important in
psychosocial programmes to address the basic, practical problems, since this would directly
improve resilience.
B.4.2 Mental
Approximately 80% of people in Western settings are able to cope with their traumatic
experiences without external support.48 Normal psychological coping mechanisms are sufficient for
most people under normal conditions in relatively stable contexts.The sooner the coping process
starts the higher the likelihood of positive outcomes.The coping process is promoted through a
relative sense of security, feelings of self-control, self-help and predictability of the environment.49
B.4.3 Social
Social support affects health by mediating the adverse effects of environmental, social, and
internal stressors.50 Social support is multi-factorial and consists of subjective appraisal of support,
supportive behaviour (e.g. participation in organisations), and the company of family and friends.
Participation in group activities also has a strong effect on physical health and functioning.51
A positive social recovery environment in the community for instance expressed through the
caring capacity, acceptance of vulnerable people, presence of a social order, clarity of and respect
for cultural and community roles, promotes resilience because it enhances control, predictability
and self-help. It fosters a sense of belonging.
Parallel to having access to social support resources the ability to mobilise and sustain them is
equally important.52
The positive effect of social support on the resilience of survivors of violence is likely to be
universal.53 However, social support is not always a resilience factor. In some populations, a large
social network made up of many family members may cause a higher level of stress.54
B.4.4 Spiritual
Western medicine, through its technological interest in the how has left individuals with chronic
or serious illnesses little help in answering the question why me?55 The healing process after a
traumatic experience in many cultures is not regarded as a simple medical solution to
psychosocial problem or mental health disorder.Traumatic experiences can lead to a major shift
in the individuals internal belief systems.They can become powerful sources of motivation for
some individuals leading to abstinence from all violence; for others they can become destructive
resulting in a obsession with revenge on perpetrators.56
Many cultures have strong beliefs in fate: the punishment of God as a divine intervention,
suffering to repay karmic debt,57 are examples. Performing rituals (especially burial) and visiting
places of contemplation or worship are powerful tools to promote spiritual health.58 The
importance of spiritual beliefs in mental and physical healing processes is increasingly receiving
attention among mental health researchers.
20
B.4.5 Moral
Moral values can play an important role in coping with adverse psychosocial effects of mass
violence, since they can provide a higher meaning or motivation (e.g. fighting for your country,
surviving to tell others, continue for the sake of the children etc.).59
Sometimes moral values are used to confirm self-control: for example, when ones own moral
values are kept and put above those of the perpetrator (e.g. what happens to me, I will not do
to others).These values can constitute important resilience factors but when they fail they may
also cause significant problems such as guilt and shame.
Tbl. 3
Mental
Feelings of control
Previous methods of coping used
Access to knowledge/ information
Access to training/ preparation
Moral
Spiritual
Social
21
CONSEQUENCES OF VIOLENCE
Psychological consequences of violence can manifest themselves on all levels of human
functioning: physical, mental, social, spiritual and moral.
Fig. 4
Resilience
Event related,
Personal,
Recovery environment
Traumatic
event(s)
Physical
Mental
Social
Spiritual
Moral
C.1
Avoidance
Integration
Intrusion
Failure
to cope
Coping process
Physical Health
People with mental health or psychosocial problems rarely visit mental health services.60
Stigmatisation and fear of coming forward are not the only explanations. Often people do
not understand the relationship between their physical complaints and mental suffering.61
Furthermore, people have difficulty articulating their emotional states and use bodily symptoms
to communicate their distress (somatisation).62
Clinicians have developed methods such as symptom checklists to identify people who suffer
from mental health disorders. Both research and field experience shows that PTSD is often
difficult to identify in basic health care settings.Taking a comprehensive view of health as well as
close cooperation between different health services may improve this.The involvement of
structures outside the spectrum of medical services like community centres may further
improve the identification of vulnerable people.63
22
C.2
Health Consequences
Increased complaints
Increased disorders
Unhealthy behaviour
Mental Health
The importance of culture in the diagnosis of mental health disorders is the focus of intensive
debate among mental health professionals.The current diagnostic system of mental health
disorders (DSM IV-Text Revised)71 has its shortcomings when used in non-Western settings.
Despite these limitations and in the absence of useful alternatives the (Western) diagnostic
system is used in this chapter.
23
Physical
Behavioural
Excessive sweating
Hyperventilation
Tachycardia
Dry mouth
Dizziness
Extreme tiredness
Frequent urge to urinate
Diarrhoea, vomiting
Migraine
Menstrual problems
Pain in the neck or back
Impulsive behaviour
Strong impulse to cry or run away
Inappropriate behaviour (eg: aggression,
prima donna behaviour)
Startle responses
Shaking or tics
Giggling or unstoppable laughing
Sleeplessness or nightmares
Hyperkinesias
Lack of appetite or excessive eating
Increased substance abuse (eg: smoking, drinking, drugs)
Neurotic behaviour
Lack of concentration
Excitation or depression
Nervousness (tensed)
Emotional instability
Feelings of detachment, weakness
Feelings of being hunted
24
There has been a tendency in Western psychiatric research to focus exclusively on PTSD when
describing the mental health or even psychosocial consequences of violence. Understanding
human responses to extreme and catastrophic experiences solely in terms of PTSD has serious
shortcomings. First, not all disorders caused by traumatic events can be described in terms of
PTSD it is not the only possible disorder after traumatic events, even according to the DSM
system. Co-morbidity (most notably depression and generalised anxiety disorder) has been
found to be more prominent in trauma clients than has been originally assumed. Secondly, and
more importantly, it has been found that many people do not develop mental disorders at all.
Although nearly all people confronted with war will suffer various negative responses such as
nightmares, fears, startle reactions and despair, they will not all develop mental disorders. An
emphasis on PTSD overlooks the normal and healthy ways of adapting to extreme stress.82
Studies of various trauma populations show that individuals who spontaneously recover from
PTSD do so in the first three months. In Western settings, which are in general more favourable,
approximately 80% of people have been shown to recover without (para) professional support.83
For this reason, the DSM-IV defines PTSD as chronic if the duration of symptoms is three
months or more.
Tbl. 6
Observed as
Hyperarousal, as indicated by at
least two of the following:
25
vii The transcultural psychiatry concept of self differs from the traditional Freudian one. It sees the self as culture-dependent, (i.e. not a static ego)
and is constantly evolving parallel to changes in its socio-cultural environment.
26
27
C.3
C.3.1 Relevance
The consequences of mass violence on social, moral and spiritual health are less obvious
than effects on physical and mental health, but the damage caused is equally devastating.
Mass violence affects individual and group coping processes. It hampers peoples ability to
redefine (individual and group) core values and social attitudes.
Evidently, social, spiritual and moral health consequences are strongly influenced by culture.
Research about the effects of mass violence on social, spiritual and moral health is growing,
but remains scarce compared to that done on physical and mental health.
C.3.2 Social health
Experiences of mass violence have a detrimental effect, first and foremost, on intimate
relationships. Problems in marriage, family life and sexual functioning, poor social support
networks or withdrawal from society are common reactions to mass violence across
cultures. Survivors often experience unstable and unsuccessful work lives such as frequent
career and job changes, low paid work or very successful ones at the expense of family or
interpersonal relationships.101
The social health of the individual directly influences the social functioning of the group. Mass
violence affects the social fabric and social capital of a community.102 Key people like traditional
and religious leaders and village elderly in the community may lose their status. A communitys
set of (un)written rules on rights and obligations (social order) may erode. Its ability to care for
its vulnerable people itself through, for instance, community self-support may be affected. Social
cohesion of the group might be diminished, as everybody is pre-occupied with their own
traumatic experience. Disharmony may increase, resulting in increased aggression or schisms.
Mechanisms that create and confirm community cohesion such as story telling, folk dancing
may disappear.
C.3.3 Spiritual health
Human beings use spirituality to give meaning to the unimaginable, the unpredictable and the
unexplainable. Spirituality, often expressed through religion, ideals or philosophical ideas is a
strong resource for fostering acceptance and integration of traumatic experiences.
In the aftermath of the traumatic experience spirituality can become a major stressor or source
of inspiration. Experience shows that survivors of mass violence can either become more
religious, expressed through increased prayer for instance, or lose faith resulting in spiritual crisis
or beliefs of being cursed.The loss of belief in the benevolence of people, authorities, religion or
a meaningful future may result in cynicism.
Rituals are symbolic ways of giving spiritual meaning to an event, coming to terms with or
controlling the unmanageable. Mass violence can reduce an individual or groups capacity to
perform rituals, due for instance to a lack of people to execute the rituals.
28
Spiritual Health
Moral Health
Survivor guilt
Shame
Outrage, anger and frustration
Revenge
Prostitution
Changed marriage rules
Shattered values and principles of basic (unwritten) community rules
29
C.4
Children
30
Children in this age group often remember one aspect of the event (not necessarily the most
important), and often endlessly repeat themes from their traumatic experience in their play or
drawing.Traumatised children often play alone.
Regressive behaviour like bedwetting or thumb sucking can occur. Social behaviour becomes
either withdrawn and silent or aggressive and demanding. Sleepwalking, talking in the sleep,
nightmares and general restlessness is often picked up by the parents as sign of alarm.These
reactions disappear over time in most cases.
C.4.4 School children
Children in the age group of approximately 6-12 years old have gained independence.They
understand better what is going on and depend less on the reactions of their parents.
The stage of development permits them to react in cognitive, emotional and behavioural ways.
Achievements in school are useful indicators for determining how well or poorly a child is
processing a traumatic experience. Achievement levels may drop and concentration difficulties may
be reported. Traumatised children may engage their school friends in their post-traumatic play.
The child deals with his powerlessness, rage or feelings of guilt by having saviour or revenge
fantasies. Since the child has developed at this stage a sense of right and wrong (conscience),
s/he may feel very guilty for not having reacted differently during the traumatic experience, and
for having revenge fantasies.
Children in this age group have a tendency to worry about their parents, and are reluctant to
bother their parents with their own fears.
C.4.5 Adolescents
Adolescence is characterized by major biological, psychological and social changes. Definitions of
adolescence vary among cultures in terms of age, roles and responsibilities.The development of
social autonomy is very important during adolescence. Friends and peers become more
important than parents. Fear of rejection, problems in developing independence, and
ambivalence towards parents are part of the uncertainties almost every adolescent is
confronted with.
A traumatic experience can seriously hinder the process of detachment. Extreme fear may
increase the sense of dependency on parents.This regression may be difficult for an adolescent
to accept. The associated loss of control and sign of weakness causes the adolescent to feel
humiliated before friends.
Adolescents generally exhibit extremely strong emotions, and are critical about themselves.
While evaluating their past traumatic experience(s), they may strongly denounce themselves or
feel guilty. Sometimes these emotions are suppressed and acted out through conflict or
aggressive behaviour. Conflicts with parents may increase and substance abuse may start.
As with children, adolescents have an instinctive urge to re-live their traumatic experience
through re-enactment behaviour such as post-traumatic play. In their re-enactment they may
take the role of a victim. However, to increase control and manage their feelings of shame they
may take on the role of the aggressor. Both may result in extremely dangerous situations as
adolescents are physically mature and often have easy access to weapons.
31
Expressions
General
Re-experiencing
Sleeping problems
General anxiety, irritability
Fatigue
Concentration problems
Infants,Toddlers
Signs of alarm
32
Post-traumatic play
Contain their emotions
Detachment
Loneliness
Obstructive behaviour
D.1
33
Fig. 5
M
E
N
T
A
L
E
Psychiatric &
psychological disorders
DISORDER
A
L
T
H
O
Psychological &
psychosocial problems
AT RISK
N
T
I
N
U
U
No problem
T O T A L
P O P U L A T I O N
34
D.2
Objectives
35
The process of coping with traumatic experiences includes the capacity to give meaning to the
experience. In many non-Western societies meaning is given through the spiritual world.
Spirituality is an important coping mechanism.The areas of moral and spiritual health are difficult
for Western NGOs and psychosocial counselors to address. Psychosocial projects can include
spiritual leaders as advisors or as referral options. Rituals and ceremonies can be stimulated.
Nevertheless, it should be born in mind that humanitarian aid workers are also bound by their
own ethical principles and quality standards.
Training: Training of national staff is necessary to increase or to introduce skills and
knowledge.Therefore, national health staff are trained to identify psychological and psychiatric
problems.They are trained on, for instance, communication skills to offer basic support to their
clients in their work settings. National counsellors are trained in two issues: to give more
intense individual support to survivors of violence and to work in the community, see D.3.2.
Socio package. A specific training method has been developed for the training of national
counsellors,108 see Chapter K Training.
Advocacy: Proximity to beneficiaries is essential for showing empathy, solidarity and
compassion.The changing environment requires ongoing monitoring of needs. Human rights
violations necessitate speaking out or advocating for those who cannot speak.
D.3.2 Social package
The social component of a project addresses psychosocial problems on a group level. A package
of activities is proposed to stimulate the re-integration of traumatised people and to facilitate
the coping of large groups of people. All components of the social package should be delivered,
otherwise resilience or protective factors can only be partly mobilised.The social package
includes the following components:
Practical support: Traumatised people and populations need a lot of practical, physical support
to enhance their recovery environment. Medical services, water and sanitation assistance or food
support are just some examples.The prevalence of needs is often overwhelming.Therefore,
to ensure appropriate referrals of those in need for practical support, expatriates, national
counsellors and community workers need to know what is available in the community (social
map).To provide adequate support and to foster self-help mechanisms the national staff s
understanding of social and culturally appropriate methods is vital. Since not all support can
be expected from the community, close cooperation among NGOs needs to be stimulated.
Community education: Large-scale education about prevailing psychosocial problems in the
community is necessary to increase self-control and self-help. Education also assists to diminish
taboos about mental health and psychosocial problems. Furthermore, it increases awareness
about counselling services.
Community mobilisation: The social fabric of communities is often affected by mass violence.
This results in a reduction of peoples protective mechanisms. After mass violence the
regeneration and revitalisation of new or former community structures often requires
facilitation from outside. Cultural leaders such as chiefs, religious leaders, the elderly must
be stimulated to re-assume their roles. Grass root initiatives need assistance and stimulation.
They often prove to be important mechanisms for the provision of practical support.
Local cultural groups like theatre, or folk play companies are often instrumental in creating
a better atmosphere.
36
Community Activities: The atmosphere in refugee and internally displaced camps is often far
from uplifting. Community activities can be used to improve the general atmosphere, to
stimulate community action on general issues like hygiene promotion, or to re-start
community cultural customs like dancing or story telling.These activities intend to improve the
sense of belonging. Extensive networking with both significant people in the community and
(folk) artists are required to achieve this.
Advocacy: Human rights are universal and must be respected. Counsellors and expatriates
have the right to speak out (advocacy) against human rights abuses and to raise awareness
about issues like sexual violence.
For a detailed description of activities see the chapter on Project Planning, Chapter J.
D.3.3 Integration and comprehensive medical services
The nature of mental health and psychosocial care requires a multi-disciplinary approach.
The evident relationship between traumatic exposure and poor health suggests intensifying the
collaboration between primary and specialty medical care.109 Collaboration is mandatory to
improve early identification and treatment.
To emphasize the collaboration mental health interventions are managed as integrated elements
of health interventions for instance through joint project planning as much as possible.
37
Fig. 6
Intervention model for psychosocial projects to address the psychological consequences of violence
through individual and community interventions.
Vulnerability
Resilience
Physical, Mental, Social,
Spiritual, Moral part
Event related,
Personal,
Recovery environment
Traumatic
event(s)
Avoidance
Integration
Intrusion
Not coped
Coping process
38
SOCIAL PACKAGE
PSYCHOLOGICAL PACKAGE
Practical support
Community education
Community moblisation
Key people
Grass root organisations
Community activities
Distraction
Networking
Advocacy
Advocacy
Psychiatric support
Counselling support
Education
Emotional support
(Social) skill training
Advice
Training other health staff
PART I1
PROGRAMMING DETAILS
39
E.1
40
Tbl. 12 Overview of acute crisis intervention strategies in MSF psychosocial, mental health projects
Crisis intervention
Support/Treatment
Avoid
Anxiety disorder
Panic disorder
Suicide
Psychosis
Acute stress disorder
(or acute PTSD)
Agitation
Stimuli reduction
Containment of emotions
Normalisation of reaction
Helping clients challenge irrational thoughts
Challenging negative thinking
Restoration of the here and now
Listening
Structuring of thoughts (and emotions)
Restoration of control (e.g. behaviour
prescription, advice, education)
Relaxation
Restoration of daily routines
Social
Provision of practical support
Exploration/mobilisation of support network
Drug therapy
See section E.2
E.2
ix In this paragraph most of the material has been taken from: (2003). Clinical Guidelines: diagnostic and treatment manual for curative programmes in
hospitals and dispensaries. Guidance for prescribing. France: Mdecins Sans Frontires.
41
42
43
These dosages must be maintained for 6 months after symptom improvement. Be aware that
the adverse effects of clomipramine and fluoxetine appear in the first days of treatment while
the therapeutic effects are not seen for 3 to 4 weeks.This must be clearly explained to the
client.
Suicide risk is increased from the 10th to 15th days of treatment. Diazepam may be added to
the treatment, particularly in clients with severe depression, severe anxiety or incapacitating
insomnia: diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses, for a maximum of 2 weeks.
E.2.6.1 Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
E.2.7 Post-traumatic stress disorder (PTSD)
At least 20% of individuals who have been exposed to traumatic events develop long-term
psychological and psychosocial problems.These problems, such as unexplained somatic
complaints, phobias, anxiety, relationship problems, depression and behaviour disorders are often
expressed indirectly, for instance, through repeated consultations in health clinics.
The short-term treatment of PTSD with benzodiazepines should only be done with great
caution.They are not very effective, may even cause future problems because clients do not
learn how to cope with or overcome their problems by themselves, and rapidly become
dependent (see paragraph E.2.2 Place of and use of drug therapy). Benzodiazepines may be
useful for a short period of time in clients with insomnia.
Clomipramine is effective against anxiety and increased arousal, and may reduce flashbacks. If
cognitive-behavioural techniques or supportive counselling fails and symptoms persist or if
depression complicates the clinical picture, administer:
Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over
several days) to 100 to 150 mg once daily.
Or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg
once daily.
These dosages must be maintained for 6 months. Be aware that the adverse effects of
clomipramine and fluoxetine appear in the first days of treatment while the therapeutic effects
are not seen for 3 to 4 weeks.This must be clearly explained to the client.
E.2.7.1 Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
Suicide risk is increased from the 10th to 15th days of treatment. Diazepam may be added
to the treatment, particularly in clients with severe depression. In cases of severe anxiety
or incapacitating insomnia: diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses, for a
maximum of 2 weeks.
44
E.2.8 Psychosis
Psychosis is an acute or chronic pathological state characterized by the presence of delusional
thoughts: the client is convinced of things that are beyond reality such as hallucinations, ideas of
persecution etc.The delusions are sometimes associated with ego splitting like in schizophrenia
or brief psychotic disorders in which there is a loss of coherence between the effect, thoughts
and behaviour and a lack of continuity in thoughts and speech.
Symptoms are improved with the use of haloperidol PO (3 to 10 mg/day) that must be
prescribed for an extended period of time. If extra-pyramidal adverse effects occur, it may be
helpful to add biperiden PO (2 mg 1 to 3 times/day).Treatment must include psychotherapy
and social therapy and, whenever available, care by mental health specialists (particularly if there
is a risk of confusion with culturally shaped manifestations).
E.2.9 Agitation
Psychomotor agitation requires a diagnostic process that is rarely immediately possible.
Do not forget medical causes like neurological disorders, infections, sepsis and toxic causes such
as intoxication, or withdrawal.
Moderate agitation without respiratory difficulty:
Diazepam PO or IM: 10 mg to be repeated after 30 to 60 minutes if necessary.
Significant agitation and/or signs of psychosis (loss of contact with reality, delirium):
Chlorpromazine PO or IM: 25 to 50 mg to be repeated a maximum of 3 times in 24 hours
E.2.10 Insomnia
There are several causes for, and types of, insomnia:
Insomnia linked to life conditions (life on the streets, in institutions etc.): there is no specific
treatment.
Insomnia linked to a physical problem: do not give sedatives, treat the cause (e.g. give
analgesics for pain).
Insomnia linked to drug therapy (corticosteroids) or use of toxic substances (alcohol etc.):
treatment is adapted on an individual basis.
Insomnia linked to a mental disorder (depression, anxiety, PTSD, delusional state):
symptomatic treatment for no more than 2 weeks may be given (diazepam PO: 5 to 10 mg
once daily at night).The underlying cause must be treated.
Isolated insomnia, usually linked to a particular event: symptomatic treatment with diazepam
PO: 5 to 10 mg once daily at night for no more than 2 weeks.
45
Tbl. 14 Summary of drugs and prescriptions in MSF psychosocial, mental health projects.
ALWAYS read accompanying text above
Drug therapy & prescription details
Anxiety
Depression
Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over several
days) to 100 to 150 mg once daily
or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg once
daily
Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
PTSD
Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over several
days) to 100 to 150 mg once daily
or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg once
daily
Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
Psychosis
Agitation
Insomnia
Insomnia linked to drug therapy (corticosteroids) or use of toxic substances (alcohol etc.):
treatment is adapted on an individual basis.
Insomnia linked to a mental disorder (depression, anxiety, post-traumatic stress disorder, delusional
state): symptomatic treatment for no more than 2 weeks may be given (diazepam PO: 5 to 10 mg
once daily at night).The underlying cause must be treated.
Isolated insomnia, usually linked to a particular event: symptomatic treatment with diazepam
PO: 5 to 10 mg once daily at night for no more than 2 weeks.
46
E.3
Supportive counselling
47
These categories are used to give direction to a counselling intervention.They are not used for
differential diagnostic purposes. Clients often express combinations of problems such as practical
problems and overwhelming feelings. It is part of the counsellors job to define, together with
the client, the most prominent complaint or area of dysfunction to be treated first. Once a
persons reaction to therapy has been evaluated, counselling support can be modified.
Lengthy intake procedures should be avoided. Counsellors should provide the necessary
support and encouragement for the client to make his own decisions. If more sessions are
required, then either the complexity of the problem is too high, the support not adequate or
transference and counter-transference are too intense. However, for most cases two or three
sessions are sufficient. If the clients problems re-occur or others develop over time the client
can return.
The counselling approach and interventions during the session are based on the principles of
cognitive behaviour brief therapy.The focus of cognitive behaviour therapy is to improve the
coping skills, to facilitate self-control and to enhance the resilience of clients. Dolls 111 can be used
to clarify situations or support the expression of emotions.
The most common interventions involve combinations of: education/information, listening, (re)
gaining control, exploring (thoughts, feelings, coping mechanisms, own solutions, support net
work), structuring, clarifying, non-directive advice, instruction, behaviour change (e.g. skills),
working through of emotions (controlled, gradual exposure), working on acceptance and on
future perspectives.
In addition, other elements of health (physical, social, spiritual, moral) are addressed: referral to
health services, social services/NGOs (for practical support, distraction activities, income
generation), involvement of support network, collaboration with traditional or spiritual healers,
or use of personal and family rituals (e.g. visiting meaningful places, family gatherings).
Lastly, advocacy or alerting authorities and local leaders about a problem can contribute to the
effects of treatment (e.g. increased protection).
48
Tbl. 15 Overview of supportive counselling interventions in MSF psychosocial, mental health projects
Supportive Counselling
Treatment/Support
Remarks
Medical setting
Psychosocial problems
Counselling service
Most common areas of intervention:
Practical problems
Lack of social skills
Symptoms, complaints &
behaviours
Overwhelming feelings
Inner conflicts
Counsellors receive
ongoing training
Clinical supervision is
mandatory
Focus on main complaint
or dysfunction
Maximum 15 sessions
(often 3)
Principles of brief therapy
49
E.4
Children
50
with unpleasant thoughts or feelings and manage his fear. These tips should be explained in
simple language, and build on existing coping mechanisms from a childs past.
The child and caregiver should also establish a daily structure of routines and activities.This
should include activities that help the child to distract him/herself.
Identification, monitoring and follow-up of children at risk should be on-going.
Social support: In addition to providing several practical arrangements the stimulation of
contact with peers is important. Within the limitations of the confidentiality a childs social
circle needs to understand what is going on.
Caregivers must be informed about how to support the childs coping process. Special
attention should be given to caregivers themselves, since it is not easy to deal with a
traumatised child. It is important for caregivers to understand how the childs condition can
influence the caregivers behaviour. If appropriate, relate this behaviour to the caregivers own
traumatic reactions provoked by the traumatised child.
Tbl. 16 Overview of basic interventions in the management of traumatised children
Stimulate normal coping activities
Physical
Mental
Social
51
F.1
Acute emergencies
Community services in acute emergencies focus on the provision of direct care for the purpose
of ensuring survival.
F.1.1
F.1.2
Information centre
Information is in certain circumstances vital for survival, and for stress or panic reduction such as
chemical/biological warfare, epidemics, highly contagious illnesses (e.g. Ebola). Information centres
are used to disseminate information about health related issues and to give practical information
(where to find what). Furthermore, the centre is used for monitoring protection and
humanitarian affairs issues. In later stages the information center can be the base from where
distraction activities are started.
To avoid rumours or misunderstandings in the population, and to build trust, information
management must be transparent, strict and consistent. Cooperation with respected members
of the community like teachers and religious leaders improves local acceptance and validity,
and ensures information is given in an understandable and culturally appropriate manner.
52
symptoms, and not by its effects on other processes such as grieving and substance abuse.118
Therefore, large group debriefings as an intervention strategy are not recommended.
A useful alternative is a health education approach in which emotion ventilation is limited and
contained.The focus is on self-control and self-help. Large group education is an approach that is
more often used in chronic crises, see Community Mobilisation and Health Education F.2.3.
F.2
Chronic crises
Community mobilisation and education can be used to stimulate the existing coping
mechanisms of large groups. Socially and culturally appropriate methods should be employed to
stimulate social support and self-help (e.g. peer groups), and to re-establish self-control among
community members.x
F.2.1
Practical support
The practical needs of the chronic emergency are usually different in nature as people try to restart their daily live and activities. Some practical needs like water and sanitation and medical
care are provided.To cover other practical needs it is important to involve and refer to
community networks and NGOs.
x In this paragraph most of the material has been taken from: Shearer, A. (2003). Community mobilisation and health education. MSF internal publication.
53
54
Provide information about back-up services: It often does not make sense to increase
awareness about certain health issues if there is no follow-up support. If health education
is given about issues that have strong psychosocial or mental health components such as
traumatic stress, sexual violence, appropriate referral services like medical staff, psychosocial
support or mental health services must be in place. Where to go for further support must
be part of the health message.
Health messages must appeal:The more fun the message, the more people will listen and
the more they will remember. Engage the audience in health education. Interact with the
group when problems or solutions are explored, or use cultural elements like (street)
theatre, role-play, poetry, story telling, folk dances, drawing exhibitions etc. to disseminate
the health message.
Materials for distribution such as leaflets, posters etc. should be designed in collaboration with
the local population.
Tbl. 17 Overview of community mobilisation and health education
Steps for Community
Mobilisation & Health
Education
Comment
Situational analysis
Target group: general population, specific groups (considerations include: security, gender
and individual safety e.g. stigma)
Operational topics: determine what knowledge is needed, what is already known, what
attitudes or reasons influence the behaviour, what mechanisms are or were used to
spread information, with whom to cooperate, and where to refer
Strategy
Method of mobilisation
Content of message
Make it pleasant
Improve understanding
Reduce unhealthy behaviours
Improve knowledge/skills (self-control & self-help)
Improve social cohesion
Improve awareness about availability of services
Promote local organisations
55
F.3
Networking
Networking is essential for understanding and addressing the needs of a local population. It
involves establishing and maintaining relations of trust with relevant members of a population,
including community and spiritual leaders, representatives of vulnerable groups and local and
international NGOs. Networking is done with a long-term perspective and must be beneficial to
all parties. It is particularly useful to:
Mobilize and support local self-help mechanisms;
Increase the referral capacity of a project by connecting it to existing local care systems (e.g.
womens groups, income generating projects);
Negotiate with beneficiaries the service delivery.
Local informants can be helpful in developing culturally accepted approaches that improve the
delivery of support.
F.4
Distraction activities
Relaxation, meaningful activities and enjoyment contribute to the adaptation process after a
traumatic event.The feeling of being a member of some form of community helps people
restore daily functioning. Organising distraction activities can contribute to this. Some examples
of distraction activities include:
Cultural activities like traditional dance, exhibitions, drumming, music concerts, street theatre
and story telling. As the name says these are based on the culture of the people.They are
often very appreciated because they give the spectators a sense of belonging and continuity.
Physical exercise such as soccer, dancing, clowning and acrobatics improves relaxation and
promotes social interaction.
Occupational activities like for instance camp cleaning, jointly cooking, teaching children,
labouring the land, repairing or maintenance and caring for vulnerable people, are useful for
increasing ownership and improving self-control.
56
Social activities
Examples
Acute Emergency
Practical support
Information centre
Chronic Emergency
Community mobilisation/Health education
Networking
Distraction: - Cultural activities
- Physical exercise
- Occupational activities
INTEGRATION OF SERVICES
G.1
Justification
Approaches focusing only on the psychological, physical, or social dimension of the clients
experiences have limited value. A separation between these entities assumes, incorrectly, a
separation of body and mind, or the human from the environment.This separation does not
hold for Western medical-philosophical reasons nor is it in tune with non-Western worldviews.
Consequently medical interventions need to have psychological and social components, even
in emergencies.
The sense of such approaches is reflected in the integration of psychosocial or mental health
components in basic health care programmes through joint logical frameworks, an attitude of
comprehensive medical thinking (patient instead of disease oriented) and an integrated
management style.
G.2
Medical staff
Medical professionals like community health workers, nurses and medical doctors come into
regular intimate contact with the emotional and psychological worlds of their clients.The
curative and palliative role of the practitioners cannot simply end with the provision of technical
support. Providing emotional support is critical to a comprehensive treatment process that takes
into consideration peoples psychological, social, spiritual and moral functioning. It involves being
compassionate about peoples feelings, applying basic communication skills and sharing
knowledge on, for instance, techniques for recovery from the psychological consequences of
violence. Providing emotional support to a client directly benefits the healing process and does
not require a specialist.
G.3
Integrated Programming
57
58
59
In areas of massive traumatisation an intense and more systematic approach is justified. Activities
in addition to those described above are started.The mental state of each child and caregiver is
screened systematically at admission.The counsellor or health staff may refer beneficiaries
directly to the counselling services if necessary. All newly arrived caregivers are briefed by
counsellors in groups on the available services, feeding programme and stress related issues.
Peer group activities for the caregivers are initiated to discuss all types of practical issues,
to provide education, and to share emotions or experiences. In these groups attention is also
given to specific problems such as the challenges caregivers might face when they re-enter
normal life. Often these groups continue to support each other after dismissal from the
feeding programme.
Group counselling and individual counselling sessions are made available to help caregivers with
specific psychosocial issues.
Trained counsellors work under clinical supervision of mental health or medical staff. Often the
number of clients in need of intensive psychosocial support is high and the services need to be
staffed with a mental health expat.
G.3.2.2 Outpatient feeding programmes for severe and moderately malnourished
The later stages of treatment of severe malnutrition and the treatment of moderate
malnutrition is often organised on a outpatient basis.The patient is seen once a week or even
bi-weekly.These programmes have an outreach system to trace defaulters and identify new
cases of malnutrition.
The health staff doing the weekly medical checkups and the outreach staff should be trained in
recognising psychosocial problems, especially when a child is not gaining weight. In famine
situations, outreach workers should be alert for abandoned children, disabled or elderly, and
people who withdraw from social life or are afraid to leave their house. Health education should
inform people about the possibility to get psychosocial support and organise referral possibilities
to for instance food for work or free food programmes.
Finally, a balanced diet in hospitals and psychiatric institutions will improve the mental state
of the patients. As with other medical activities, food and nutrition support increases efficacy of
the treatment.
60
Prevalence
psychosocial needs
Psychosocial activities
Inpatient:
Therapeutic Feeding Programme
Paediatric ward in hospital
Low
High
Outpatient
Ambulatory treatment (part TFC)
Supplementary Feeding Programme
Low
High
61
Alcohol abuse
Stimulate daily routines that address cognitive, social and physical needs
Initiate activities in the hospital
Provide distraction material
Initiate group activities
Psychiatric disorder
HIV suspect
62
G.3.4.1.1
63
Anxiety disorder
A person can be identified as having anxiety disorder if s/he has been worrying for a
period of six months and exhibits at least three of the following symptoms:
Restlessness or feeling keyed up;
Easily fatigued;
Difficulty concentrating or mind goes blank;
Irritability;
Muscle tension;
Sleep disturbance (difficulty staying, or falling asleep);
Clinically significant distress or impairment in social, occupational or other important
areas of functioning.
Mood disorders:
Depression & suicide
Manic disorder
Psychosis
Sleep disorders
Cognitive disorders:
Minor cognitive motor disorder
Dementia complex
Substance abuse
Delirium
xiv Aphasia: language disturbance. Apraxia: impaired ability to carry out motor activities despite intact motor function. Agnosia: failure to recognise or
identify object despite intact sensory system.
64
G.3.4.1.2
65
Fig. 8
Overview of the links between the tasks of Voluntary Counselling and Testing (VCT) counsellors
and other services xxvii
Social services:
widow and
orphan care
Acceptance of,
and coping with
serostatus HIV
HIV campaigns:
awareness and
behavioural change
PLWA activism:
Destigmatisation
and normalisation
Peer support
groups for PLWHA
PMTCT
VCT
STI
Information,
education,
communication
Psychiatric and
pychosocial care
Medical care
(ARVs, TB, OI)
Treatment
Opportunistic
Infections
It is important to note that in the context of an HIV/AIDS project a counsellor is often referred
to as a VCT-counsellor.xviii Frequently, this results in a limitation and misconception of the
counsellors tasks: there may be a strict focus on the testing component and little follow-up or
emotional support.
It is strongly recommended by UNAIDS 134 that the counsellors role be expanded beyond VCT
services for several reasons:
The counsellor is in the unique position of establishing a close relationship with the HIVpositive person. A trusting relationship between client and counsellor has been shown to
positively influence behaviour change (safe sex, healthy living), the early identification of
symptoms, the facilitation of social functioning, and improved adherence135 to drug regimens;
If a counsellors professional responsibilities are limited to VCT, the counsellor is likely to
experience burnout or motivation problems.
xvii Adapted from: UNAIDS (2002). Report on the global HIV/AIDS epidemic. New York: Joint United Nations Programme on HIV/AIDS.
xviii Before being trained as a VCT counsellor people often have diverse professional backgrounds: medical (e.g. nurse, community health worker,
psychologist, psychosocial counsellor, mid wife) or non-medical (e.g. teacher, business man, etc.).
66
G.3.4.3.1
G.3.4.3.2
G.3.4.3.3
67
G.3.4.3.4
Policy implications
The following practical and policy issues are especially relevant to VCT counsellors and
must be considered prior to initiating any comprehensive and community-based programme:
1. Determine to what degree comprehensive care is possible.
2. Ensure that counsellors are aware of all existing medical and social support networks
to appropriately support and refer clients.
3. In AIDS care, ensure that the counsellor works in the context of a multi-disciplinary
team (medical, para-medical and psychosocial support staff).
4. Integrate support services into other medical services. Parallel (or vertical) mental
health or psychosocial programs are not recommended in the context of HIV/AIDS
programs.
5. Provide psychosocial support in HIV/AIDS programmes by a (national) counsellor
together with specialist mental health professional (expatriate or national).
6. Ensure counsellors have full responsibility for:VCT (pre and post), and follow-up
supportive counselling in all phases of the disease.
7. Ensure that counsellors have a part-time facilitating role in post-test clubs, community
education, see also Chapter G.3.4.3.4, adherence, home-based and palliative care.
8. Train counsellors in both VCT and emotional supportive counselling skills.
9. Extend the training content and policy as described in Chapter K with specific
knowledge and skills required for VCT and specific HIV/AIDS related problems (e.g.
adherence).
10. Continue training during programme implementation.
11. Provide training appropriate to counsellors levels of experience and job description
within the continuum of care. (For an overview of qualifications, roles and
responsibilities of the VCT counsellors, see Table 22.)
12. Implement a staff care system in each HIV/AIDS programme (see also Chapter M).
68
Senior counsellor
Has significant counselling experience and
advanced counselling training
Has knowledge of psychiatric disorders &
palliative care
Is experienced in the provision of training
& clinical supervision
Professional counsellor
Has a professional background
(e.g. nursing, teacher)
Has received VCT pre/post training
Has received community education/facilitation
training
Is receiving ongoing (psychosocial) counselling
training on various psychosocial topics
Is receiving regular clinical supervision
Lay counsellor
Has received VCT pre/post training
Is receiving ongoing (psychosocial)
counselling training
Peer counsellor
Has a similar background to clients (including
post-test negative, PLWHA)
Has attended an HIV/AIDS course (incl. Pre-test)
Has received basic community
education/facilitation training
Has received an introduction course to
(psychosocial) counselling
69
70
Level
Staff involved
What to do
Normal prevalence
in each programme
Health clinic
Medical staff
Elevated prevalence
Health clinic
Medical staff
OPD or
Specific NGOs
National or
expatriate counsellor
Medical care
Basic psychosocial care (see Tables 12 & 15)
Train national staff (in awareness & intervention)
Intensive counselling support either individually or
in small groups (see also Table 15)
Focused education in medical facility
Advocacy
Health clinic
Medical staff
High prevalence
71
72
Syndrome or symptoms
Comment
Anthrax
Meningitis
Brucellosis
Q fever
Malaise, fatigue
Encephalitis, hallucinations
In 1/3 of clients
In advanced cases
Botulinum toxin
Depression
Viral Encephalitis
Delirium
73
Tbl. 25 Management and staff considerations for mental health interventions in populations affected
by Chemical and Biological Warfarexxi
Phase
All Phases
Management considerations:
Assess security situation daily
Establish clear security and evacuations plans and procedures
Establish Helping the Helpers system (peer or professional psychosocial care-unit)
Address ambiguous situations by making strict rules for behaviour.This reduces stress and
enhances performance
Monitor work/rest cycles of staff, and watch out for masked symptoms and over-dedication
Organise regular, fixed drink breaks for staff to avoid heat casualties
Create openness between staff members and regularly discuss concerns about safety and
contamination
Institute a zero tolerance policy for alcohol in and around the working place
Be sensitive to staff problems, concerns, especially regarding exposure to low dosage CBW
If low dosage exposure is suspected, do not hesitate to immediately send people to an
outpatient department
Prepare for panic management:
Compose a preparedness plan
Disseminate structured and consistent information to community; build trusting relationships
with leaders and involve host community in composing and conveying information
Implement appropriate public self-protection mechanisms
Conduct ongoing community education about various health issues
Consider establishing an information centre
First Aid
(Outreach, triage
ground)
Management considerations:
Brief first responders on their security management and medical, mental health
case management
Staff considerations:
Bring clients to safety immediately
Prescribe anti-psychotic & anxiolytic medication
Use crisis counselling intervention techniques (e.g. containment)
Stabilise cases with acute traumatic stress
Inform clients or family about normal side effects of drugs
When possible involve family members in the care of clients
Second phase
(Basic health
care unit)
Staff considerations:
Prescribe anti-psychotic & anxiolytic medication (treatment simple and conservative)
Use crisis counselling intervention techniques (e.g. containment)
Stabilise cases with acute traumatic stress
Provide time and resources for emotional ventilation (or frank and open discussions)
Focused provision of psycho-education and information
Involve natural caregivers as client monitors
Organise (camp) outreach for medical and psychological cases
Stabilization
Phase
74
ADVOCACY
The combination of medical aid and witnessing is MSFs defining principle of humanitarian action.
MSF bases its advocacy on the direct experiences of beneficiaries in addition to medical data.
In psychosocial projects or components addressing the psychological consequences of violence,
mental health counsellors hear many powerful stories and, through their client relationships, have
access to information that is relevant for advocacy. However, the role of counsellor and a
person taking witness statements such as a humanitarian affairs officer should not be mixed for
several reasons:
The use of information derived from a therapeutic relationship for public advocacy is a
violation of confidentiality within the counsellor-client relationship.
One needs to remember that counselling is not concerned with discovering the truth or
reliable accounts of what happened, but with the perceptions of the client.
Clients may distrust counsellors pledge of confidentiality. Sometimes these are justified, given
the substantial abuse of psychiatry and mental health information in some contexts such as
the use of psychiatric institutions to hold political dissidents in ex-USSR or currently in China.147
Despite these challenges, witnessing and advocacy activities in psychosocial or mental health
programmes can facilitate a clients healing. If properly handled, as set forth in special
guidelines,148 advocacy can be an important part of the healing process. It can strengthen
beneficiaries coping mechanisms and help empower them.149
In order to acquire useful advocacy material, and to secure the clients healing process, some
directions need to be taken into account:
Expatriate staff must train all national staff on advocacy and witnessing.The purpose of training
is to inform and educate the staff about the organisation and advocacy, to review the content
and use of specific guidelines and to discuss local or cultural adaptations. All national staff should
be trained on the principles of confidentiality, including limitations in access to client files.
General programme information can be used for advocacy purposes.The use of data as part
of an advocacy strategy requires the involvement of headquarters line-management and
humanitarian affairs advisors.
Witness statements can only be taken if the initiative comes from the beneficiary. Counsellors
should not force clients to provide witness statements.
If a beneficiary wants to testify his story in the absence of a humanitarian affairs officer in the
project, expatriate staff together with national staff can examine advocacy options for the
client in the local context.
The beneficiary should receive supportive counselling during the advocacy process when
requested. Special care is required to avoid indentification of the witness.
Since community health workers are not bound to confidentiality by a professional code of
conduct (as is the case for other health professionals), the humanitarian affairs officer can
interview them about beneficiaries experiences.
MSF Advocacy Guidelines and management should be consulted prior to initiating any major
advocacy activity.
75
Comments
76
PART I1I
SPECIFIC TOPICS
77
FIELD ASSESSMENT
I.1
Justification
Psychosocial assessments are prompted by needs in the field. It is preferable that the field teams
(including expatriates or emergency team members) should execute the assessment under the
supervision of the Medical Coordinator and with support from headquarters staff.To execute
an in-depth assessment, a person with experience in psychosocial interventions is needed.
The goals of a psychosocial assessment are:
To identify the physical and locally defined mental health needs of a population affected by
mass violence;
To research positive and negative coping and resilience mechanisms in the population;
To understand the factors that influence peoples access to health care (e.g. socio-political
and ethnic dynamics);
To discover the expected outcome of the intervention among the population (indicators of
success); and
To identify appropriate programme strategies.
Public health principles that aim at the highest possible health impact are not the guiding
principles for assessments. Particular focus is given to identifying the needs of vulnerable or
marginalised groups.Vulnerability of groups is defined in terms of morbidity (e.g. presence of
symptoms), mortality (e.g. suicide), exclusion from care, human rights abuses, denial of the
beneficiarys dignity and specific conditions that increase vulnerability (e.g. psychiatric institutions).
Psychosocial assessments range in duration from one day, in acute emergencies that require
immediate intervention, to three months in pre-established projects that require fine-tuning
and anthropological analysis.The average assessment lasts three weeks. Informal psychosocial
assessments should continue throughout project implementation to enhance fine-tuning of
the activities.
78
Who
Field teams
Final stage: person experienced in psychosocial components (in-depth assessment, intervention advice)
Focus on
Perspective
Duration
Priority
Target Group
Most vulnerable (morbidity, mortality, exclusion from care, human rights abuses, denial of their dignity,
specific conditions/situations)
I.2
Ethics
All staff involved in the needs assessment must respect the professional ethics and principles of
humanitarian medical aid.150 Those most applicable to the needs assessment are: do no harm,
awareness and respect for cultural or ethnic variation and concerns, and confidentiality.
To protect the rights of participants for survey studies (i.e. interview subjects), informed consent
is necessary. Informed consent has various criteria:151
Information about the survey and objectives must be clear to the participant
The procedures, time investment and possible remuneration must be clear
The participant should always be free to stop his/her cooperation
The benefits of the study for the community should be made clear
The use of data and the possible consequences for the individual should be explained
It should be clear to the participant that refusing participation will not have any effect on his
treatment or well being
Preferably, the participant should sign an informed consent paper
The process of obtaining information may burden or even emotionally upset informants. During
the assessment the need for information must be balanced against the potential harm it might
cause to participants. A useful criterion in dealing with this dilemma is to continuously ask
yourself: What is the relevance of this information for the overall analysis? The person or team
that executes the assessment is obliged to secure basic medical or psychosocial follow-up for
those participants in need.
Special support should be provided to national staff, such as translators, who may be exposed
to potentially harmful and emotionally upsetting stories. Such support includes: preparation,
limitation of exposure in time, provision of emotional support when necessary, daily operational
debriefing, and counselling support when necessary.
I.3
79
I.3.1
I.3.2
Assessment instruments
Each assessment must use at least two different quantitative and three different qualitative
instruments.The use of more instruments enlarges the scope, and improves the reliability and
validity of findings.
I.3.2.1
Quantitative instruments
Health care data and mental health statistics from health posts, clinics or hospitals
are the most easily accessible type of quantitative information.They provide a quick
overview about the extent of medical and mental health problems met by a health
system and any changes in prevalence.
Psychosocial Questionnaires153 are structured interviews used for the large-scale
appraisal of psychosocial needs in closed (camp) and open (community) settings.
They are used when medical data are unreliable, but substantial psychosocial needs
are expected. Design, adaptation and translation for local circumstances are required.
Psychosocial questionnaires provide insight into the events (exposure, witnessing), the
psychological impact (for instance through Impact of Event Scale (IES154)), the
prevalence of specific health complaints and stress (for instance through General
health Questionnaire 28 (GHQ 28155), Self Reporting Questionnaire 20156) and local
knowledge, attitude, and self-help mechanisms.
Symptom checklists like for instance the Hopkins Symptom Check List,157 IES, SRQ 20,
and GHQ 28 can be used to assess the prevalence of psychosocial stress symptoms
in a population. Symptom checklists are in general not validated for non-Western
cultural environments.There is no instrument that measures the complete range of
traumatic experiences of refugees.158
Self-completion questionnaires are useful to rapidly obtain specific information on
a topic.These short open-ended questionnaires are used to obtain information about
sensitive subjects.
Knowledge Attitude Practice and Behaviour studies are used to gather basic
information about local context.
I.3.2.2
Qualitative instruments159
Qualitative instruments are essential to understanding beneficiaries perspectives on the
local psychosocial consequences of violence in terms of health and functioning, on ways
of expressing emotional distress (including vocabulary used), on psychosocial self-help
(coping) mechanisms and on other sources of relief and expected outcomes of an
intervention among the beneficiaries.
80
81
A Venn diagram exercise is used to find out which group(s) must be included
to address the top priority problem.Through this exercise it should become
clear which people are most affected by the problem, who is responsible
inside and outside the community for addressing this problem, who (inside
and outside the community) is currently addressing the problem and with
which groups (or organisations) cooperation is required.
Workshop: it is useful in nearly all circumstances to organise a workshop with
beneficiary stakeholders to discuss the assessment. During the workshop a facilitator
should be present. He then offers assessment results, analysing the relationship
between problems (the problem tree) and what needs to be done (the intervention).
This is also a good opportunity to discuss how changes and results can be observed
and measured as indicators of success.
Dictionary: during the assessment, special words, definitions, expressions, symbols,
explanatory mechanisms and rituals related to psychosocial problems can be
described in a special file.
Tbl. 28 Overview of assessment methods and instruments
82
Quantitative Methods
Instruments
Always use:
Qualitative Methods
Instruments
Always use:
I.3.3
Validation of information
To ensure the validity of information (especially from qualitative methods) various sources of
information are used. Expatriate and national staff from local, national and international
organisations should all be consulted, as well as staff from government health care institutions,
local care providers (formal and informal) and key people in the community.
It is evident that the beneficiaries themselves play an important role in this process. To what
extend they are included in the assessment process depends on the situation and the time that
is available.
Minimum information requirements for an assessment include different levels of suffering (mildly
and seriously affected), both genders, different age groups, various educational and social
backgrounds.The validity of the assessment increases when a variety of methods are used and
more beneficiaries from different social strata are included in the assessment.
I.3.4
Triangulation of data
Psychosocial suffering after mass violence is mainly caused by exposure to traumatic incidents
and environmental conditions (trauma severity).The psychosocial suffering is further aggravated
by the impact of the trauma severity on all segments of the individuals health (conflict related
health needs). However, individual, group coping and resilience mechanisms (resilience
indicators), or availability of resources dampen the overall impact of the traumatic exposure.
It is necessary to analyse a populations severity of trauma, conflict related health needs, their
resilience mechanisms and available resources to determine appropriate programme responses
(response intensity).
Triangulation is the use of different sources and methods to verify validity or to find the truth
when information is conflicting or inconsistent. Based on triangulated data a conclusion of the
assessment can be drawn.
It is important to note that triangulation adds value to the assessment. Psychosocial
consequences of violence cannot be reduced to sets of symptoms and signs. Especially in
contexts of chronic crisis the loss of functioning, the impairment and suffering of both individuals
and communities escape the medical nosology of symptoms and disorders. A comprehensive
view is required to increase understanding about the beneficiarys perspective and suffering. It
promotes our proximity and efficacy.
Instruments
Validation of
information
Different groups: at least consult beneficiaries, health staff, local care providers, key community people
Different perspectives: consult various levels of suffering, different gender & age groups, various
educational and social backgrounds
Triangulation
of data
83
I.4
Fig. 9
OUTSIDE SUPPORT
PLANNING
When?
RESOURCES
RESILIENCE
Mental
Physical
Local NGOs
TRAUMA SEVERITY
Events, signs & functioning
International NGOs
Moral
Social
Spiritual
INTERVENTION
Who?
What?
How?
Success?
I.4.1
Target Population
Purpose
Activities
Indicators
Early indicators
The majority of early indicators are related to trauma severity such as high incidence of human
rights abuses described by clients.The most striking indication of increased psychosocial needs is
a high level of conflict related health problems like war wounded and cases of sexual violence,
mental health disorders such as psychosis, depression (suicide) and PTSD, and stress related
problems, for instance traumatic stress, psychosomatic complaints and sleep problems. Clients
often report and complain about changes in their social environment shown for instance
through increased levels of community violence, disharmony and conflicts, and about poor
recovery environment.
84
I.4.2
85
Tbl. 30 Overview of factors important for early assessment and monitoring of psychosocial needs
Early Indicators & General needs assessment (field team)
Assessment Tool
Quantitative
General health
monitoring
Mental health statistics
Qualitative
Reports
Focus Group Disc
Key informant interview
(clients, leaders)
Listening,
Observation
Resilience indicators
Resource availability
Physical health
Good health
Healthy behaviour
Physical activities
Favourable living circumstances
Mental health
No increase mental health pathology
Feelings of control
Previous ways of coping
Knowledge/information
Training/preparation
Social health
Social & emotional support
Ability to mobilise social support.
Cohesive community (caring capacity,
community sense, acceptance of
vulnerable people)
Active community member
Social structure/ order
Safety, security
Community in relative harmony
Continuation of traditional
activities/festivities
Respected leaders in the community
Self control (e.g. self income generation,
authority of significant leaders)
Self initiative (e.g. with regard to
camp/shelter organisation)
Self help
Family/friends
Self help groups
NGOs (local & international)
Institutions (social welfare, schools,
work related)
Community leaders
Communal places & festivities
Quantitative
Health statistics
Number of mental health
specialists per 10.000
Policy document
Qualitative
Reports
Focus Group Discusion
Key informant interview
(clients, leaders, quality
mental health education,)
Listening
Observing
Response Intensity:
High:
Low:
stop assessment
xxii Increased (traumatic) stress complaints: headaches, sleeping problems, hypertension, palpitations, general body pains, short breath, hyperventilation,
(low temperature) fevers or local expressions of this.
Increased morbidity: cardio-vascular (e.g. hypertension), eczema, respiratory diseases (e.g. bronchitis), non-sexually transmitted diseases (e.g. peptic
ulcers, large bowel problems), pregnancy related problems, severely wounded.
86
I.5
In-depth assessment
The objectives of the in-depth assessment are to confirm the findings of the general field
assessment; to further clarify the social, spiritual and moral health issues (signs and disruption,
resilience, resources); and to give advice on future intervention possibilities. A person with
experience in psychosocial programming should execute the in-depth assessment in close
cooperation with the field team management.
I.5.1
Problem tree
An in-depth assessment gives insight in the root causes of the problem(s), the effect it has on
individuals, the functioning of the community and appropriate project response.The analysis
results in a problem tree that shows possible causes, effects and relationships between the
various aspects of the problems and actors. If time permits it is useful to discuss the contents of
the problem tree with representatives of the beneficiary population.
The decision to add a psychosocial component to existing services (or in some circumstances
to start a vertical programme) depends on the outcome of the in-depth assessment and the
problem tree.
87
Assessment Tool
See early indicators & general assessment: continue what is not finished
Quantitative
General health monitoring
Mental health statistics
Individual psychosocial stress
symptoms
Psychosocial questionnaire
Self-completion questionnaire
KAPB-study
Resilience indicators
Resource availability
Quantitative
Existence of laws and justice
mechanisms
Qualitative
Reports
FGDs
Key informant interview (clients,
leaders)
Listening
Structured observation
Diaries
Social mapping
Hierarchy mapping
Village drawing
Dictionary
Workshop (results, problem tree
analysis, intervention, expected
outcomes)
Religious institutions
(formal/informal)
Places of worship
Possibility and frequency of healing
rituals (e.g. memorials, burials)
Qualitative
Literature
FGD
Key informant interview
Listening,
Observing
Moral
Ability to forgive, have compassion
Justice system
Acknowledgment of and adherence to
Law
ethical rules/regulations
(In)formal rules on marriage,
Sense of contribution to a greater goal
heritage etc.
Drive to survive to serve a higher purpose
Overall conclusion about response intensity & possibilities for intervention
High Response Intensity: implement psychosocial project or component
High indicators of psychosocial problems, low signs of resilience and poorly developed resources
Normal level of psychosocial problems, low signs of resilience and poorly developed resources
Marginalised or other affected groups
Possibilities for intervention
Psychosocial component added to other programme activities or to a full community-based programme
Intervention is supported by staff
Realistic plan
88
PROJECT PLANNING
J.1
Definitions
Humanitarian aid has traditionally consisted of providing life-saving assistance to populations
in danger during acute emergencies such as violent conflicts, natural disasters, and epidemics.
This type of assistance is considered distinct from development assistance, which focuses on
socio-economic rehabilitation in relatively secure areas.Today, NGOs find themselves working in
contexts that do not conform to either description, but lie somewhere in the middle of the
emergency development continuum. Often these situations are defined as chronic emergencies
because health and security environments are under constant threat. In such situations, neither
a pure emergency nor a pure development assistance approach is appropriate. Projects in
chronic crises must combine objectives, activities and strategies from both models of assistance
to ensure effectiveness.
The critical question for programme managers is, then: which operational strategy will best meet
the needs of the population? This question occupies many health professionals working in
contexts of chronic crisis.
In this chapter a rather strict separation between three forms of assistance (emergency, chronic,
development) is used as a model to explain what psychosocial projects should look like in the
various contexts.160
Three types of indicators are generally used to describe the success of a project.
Outcome indicators: related to Project Purpose
Output indicators: related to Specific Objectives
Process indicators: related to Activities
Process indicators assume a positive correlation between the activities and the specific objective.
The assumptions are mentioned in the logical framework. Outcome and output indicators prove
(instead of assume) the relationship between the activities and project purpose or specific
objective.161 Ideally, all psychosocial projects strive to define outcome indicators to provide a
basis from which to measure the effectiveness of their intervention. Realistically, most projects
define output indicators.
The areas of conflict or high instability in which MSF intervenes hardly ever allows for the
definition of impact indicators (related to the overall programme purpose).
89
J.2
J.2.1
Project purpose
The project purpose is to support individual human physical survival by delivering care to
preserve lives and provide basic subsistence.
J.2.2
Specific objectives
The use of standard specific objectives and indicators (see table 32) is justifiable for an
emergency context where actions are limited by time and security. Within mental health or
psychosocial services direct treatment and care for mentally affected beneficiaries is the highest
priority in emergencies. When possible these activities should be provided along with
psychosocial care activities.
Mental health projects may also enhance the efficacy of other life saving services in the
Outpatient Department (OPD). A large flow of shocked, distressed, anxious and somatising
OPD patients can, for example, be referred to the mental health services. Outreach services are
useful to enhance the identification of vulnerable people (physical and mental). Psychosocial
education should be used to stimulate the self-help mechanisms of individuals or small groups.
The preservation of human dignity and assurance of protection are important. In emergency
medical assistance, ensuring dignity and security is an ethical imperative.
J.2.3
Indicators
The identification of reliable outcome and output indicators is not possible in emergency
settings due to the fast changing situations. Process indicators related to activities are often the
most valid indicators of programme effectiveness in emergencies.They show how activities are
saving lives and improving human dignity. Examples of useful process indicators include:
Number of people identified through outreach and number treated: These process indicators
assume that in emergencies, early identification and treatment of vulnerable people (both
physically and mentally affected) results in the improved likelihood of survival. Indicators of
enhanced self-help and self-organisation of clients are often described in terms such as all
clients are receiving support from their social networks who have received psycho-education.
Number of people referred: Psychosocial and mental health interventions improve the physical
survival of clients by affecting the output of other medical programme interventions. For
instance, in a nutritional crisis recovery from therapeutic feeding is enhanced through
psychiatric care for depression, and psychosocial support for clients and caregivers through
improved mother/child interaction. In basic health care institutions mental health services
reduce the strain on medical staff services by dealing with somatisation complaints or signs of
emotional stress. Encouraging survivors of violence to share their emotions, listening to their
stories and promoting self-care through small group education sessions, can increase the
efficacy of basic health care services. It also contributes to the human dignity of the
emergency medical services.
xxiii The format used for describing project planning in this chapter has been described before by Damme,W. van, Lerberghe,W. van & M. Boelaert, (2002).
Basic health care versus emergency medical assistance: a conceptual framework. Health Policy and Planning, 17 (1), 49 - 60.
90
Protection and safety: Providing a safe place for beneficiaries to seek treatment directly affects
survival. General indicators are monitoring human rights abuses and advocacy actions.
However, specific indicators related to increased safety of women, children, severely (mentally)
ill, elderly are defined during the emergency.
Number of clients counselled:The respectful and humane treatment of clients, by paying
attention to their emotional suffering, improves the sense of human dignity.
J.2.4
Target group
As part of the emergency medical package, mental health services should focus on the most
vulnerable, including: psychiatric clients, suicidal, acutely shocked or traumatised, mentally disabled,
withdrawn people, and other identified vulnerable groups such as children, victims of sexual
violence and the elderly.
J.2.5
Time perspective
Emergency mental health projects range in length of implementation from days to several
weeks, and up to a maximum of 3 months.
J.2.6
Activities of care
Once the target population has been defined, and clinical and outreach services with
appropriate referrals have been established, several activities of care are in place:
Primary support that focuses on stabilizing the client through drugs, crisis counselling, and that
ensures clients have an (informed) social network to support them, for details see Chapter E
and Chapter F.
Psychosocial counselling that allows for expression and ventilation of emotions, promotes selfcontrol and provides advice.
Outreach services that identify vulnerable beneficiaries with physical and mental health problems.
Education and cooperation with existing social networks.
Mental health services that contribute to the protection and safety of beneficiaries by
monitoring human rights abuses and speaking out about them (see Chapter H for guidelines
on Advocacy).
J.2.7
Structure of services
Psychosocial services must be integrated into an outpatient department. Access can be
maximized through outreach workers who identify mentally and physically vulnerable cases at an
early stage. A referral system between physical and mental health services should be
encouraged. Sometimes an information and educational facility is identified to further reduce
strain on the medical and mental health services.
In contexts of limited accessibility mobile services are an option. In these cases, mental health
and, secondarily, psychosocial assistance focus only on acute cases.
All services are executed under the clinical supervision of a certified mental health worker.
91
J.2.8
Human resources
Expatriate psychosocial worker(s) with a team of (inter) national caregivers (counsellors and
outreach) are responsible for providing mental health and psychosocial care services.Though the
involvement of local professionals is preferred, expatriate caregivers such as psychiatrists,
(clinical) psychologists, social workers, teachers can participate in the provision of care.
A basic unit of two expatriates (preferably one psychiatrist), 5 trained national counsellors and 8
outreach workers can effectively cover curative and preventive first-line activities for
approximately 10,000-15,000 people. If possible, staff should be recruited among beneficiaries
and should work on short-term contracts.
When psychosocial services are implemented through mobile teams, staff is often limited to one
or two (expatriate, national) staff.
J.2.9
Training
Training of (expatriate or national) medical and outreach staff is limited and focused on the
execution of standardised tasks.
92
Tbl. 32 Summary of essential features of a mental health and psychosocial intervention in an acute emergency
Mental health and psychosocial care in acute emergencies
Project purpose
Specific objectives
Indicators
Output indicators:
Cross-culturally valid indicators cannot be developed within short time periods and rapidly
changing contexts
Process indicators:xxiv
Number of stress related complaints and disorders treated in OPD
Number of psychosocial & psychiatric clients seen and supported.
Appropriate cross referrals made by physical & mental health and outreach services
All clients receive respectful, humane treatment (e.g. attention to emotional suffering of
the client)
All significant members of social networks received psycho-education
All clients are supported by informed social networks
Monitoring of human rights abuses (including sexual violence)
Advocacy action on safety and security issues of beneficiaries
Target population
Time perspective
Activities
Structure of
Services
Human Resources
Training
Strategy
xxiv If process-indicators (related to activities) are used the assumptions need to be mentioned.The relationship between the process indicator and
the specific objective has to be proven in other contexts (e.g. treatment of psychiatric clients in crisis situations reduces morbidity and mortality).
93
J.3
J.3.1
Project purpose
The purpose of a psychosocial project in a chronic crisis is to improve the daily functioning of
the most vulnerable.To help people cope with such a situation, we need too look beyond basic
physical survival and protection to build social and emotional endurance.
J.3.2
Specific objectives
Specific objectives for a psychosocial project in chronic crises cannot be standardized for
two reasons:
Firstly, the nature of a chronic crisis is that of uncertainty. Both deterioration and amelioration
of the social and security context are possible. Inevitably, a mixture of acute emergency and
post-crisis specific objectives are necessary to ensure a built-in flexibility.
Secondly, projects in chronic crises need to address the specific, locally defined consequences
of violence.Therefore, a context and culture specific problem tree is needed to further define
the specific objectives.
Often specific objectives include the improvement of knowledge, and skills for self-management
of psychosocial problems and improved functioning of beneficiaries.
J.3.3
Indicators
In principle, psychosocial projects in chronic crises need to design cross-culturally validated
outcome or output indicators. Whether or not it is possible to do so depends on the context,
the willingness of the team, and the amount of time and resources available to the project.
Locally developed outcome or output indicators should be developed with the assistance of the
local population.Through Focus Group Discussions (FGD), and key informant interviews, the
beneficiary perspective of the psychosocial problems is researched. Consideration should be
given to how locals interpret the improvement of their physical, mental, social, spiritual and
moral health, and to how it can be measured. It is suggested to describe the locally defined
outcome, or output indicators for both the psycho and the socio-component in terms of
functionalityxxv and coping, for instance the improvement of social contacts, ancestors are resting
in peace, decreased worrying, improved physical activities, improved ability for self-care,
improved family relationships, and increased number of daily activities etc.
It may not always be possible to develop locally defined outcome, or output indicators e.g. in
situations with security constraints, lack of human resources, insufficient educational level of the
staff, inexperienced expatriate or project team. It must be noted, however, that the use of
process indicators hinders a proper effect evaluation of the specific objective or project purpose.
In these circumstances process indicators can be used to describe the effectiveness of the
programme. Assumptions have to be described in the logical framework. A combination of
qualitative and quantitative indicators is highly recommended:
xxv Functionality is a dynamic term that refers to both physical survival, psychological and social performance. It is defined in close connection to other
parts of the local society, the context and the prevalent culture. Contrary to indicators in post-crisis programmes, functionality is described in
terms of (long-term) survival, coping and not in terms of well-being.
94
Target group
The target population is those individuals who suffer from the psychosocial consequences of
violence.The psychological or emotional suffering can either be caused by a direct impact from
traumatic experiences or indirectly through lack of protective mechanisms (see B.4 Resilience).
J.3.5
Time perspective
Project implementation can vary in length of time from six months to up to three years.
J.3.6
Activities of care
The types of activities of care offered by a psychosocial programme depend on the level of
intervention, Figure 7 and Chapter G.3.
Given the chronicity of the situation, endurance is promoted through increased functioning of
the individual.Thus victims coping mechanisms and resilience resources (physical, social, spiritual
and moral) mechanisms are reinforced.
On an individual level (as described in detail in Chapter E), coping is supported through crisis
and supportive counselling.This is the psycho -component).
To further reinforce resilience mechanisms for the individual, community resources can also be
included in the intervention (the socio -component). Chapter F describes how, for instance,
psycho-education can be included in general health education, a referral network of NGOs
can be organized, local organisations and traditional mechanisms of care and coping can be
mobilised. Community leaders and other influential members of the community such as
school teachers, medical professionals are encouraged to re-assume their traditional,
previously held, roles in society. Distraction activities to improve the atmosphere may be
included in the activities.
If protection and human rights issues emerge they need to be monitored, and if
possible addressed.
95
J.3.7
Structure of services
Psychosocial projects in chronic crises have to deal with a dilemma about whether to
integrate mental health into existing services or establish a separate vertical system. In many
non-Western countries psychosocial, or even mental health services, are often non-existent or
underdeveloped. Chances of building a sustainable service are low. Despite the low probability
of sustainability MSF chooses to realize psychosocial and mental health interventions. For this
reason sustainability of the services has low priority in programme implementation.The choice
must not exclude close collaboration with the community (local representatives, NGOs), and
with existing health and social services.
MSF has chosen to address psychosocial and mental health needs when there is a marked
prevalence of mental or psychosocial dysfunction in a population. Systems building and
sustainability are not a priority for MSF.The first priority is to establish a proximity to the
beneficiaries that enables us to address their needs through the provision of quality care. In
extreme circumstances this may result in MSF initiating a separate, temporary programme that is
parallel to existing national health services. Most psychosocial projects in chronic crises are
closely connected to the existing health care system (e.g. through training or referral).
Experience shows that in reality the services are seldom continued by the local health system
after the crisis.
Psychosocial support in chronic crises can take on a variety of forms:
Basic support as provided in each medical relationship;
Psychosocial referral service (local NGO, national or expatriate specialist);
Psychosocial community-based programme (see Chapter G.3, Figure 7).
Psychosocial care should be implemented in an OPD. Psychosocial care services must be
executed under the clinical supervision of a certified mental health expatriate. Where possible, a
local counterpart (mental health professional) can also participate in the clinical supervision
process.
Connectedness to the community (the social component) is very important. To stimulate selfhelp of the individual and the community, a local referral support network outside the health
system needs to be used.
The implementation of psycho-educational awareness activities in the community is only
possible when clinical back up is available.
J.3.8
Human resources
A team of 1 expatriate, 5-10 trained national counsellors, and 10 community workers can
effectively assist a population of 15,000-20,000 people. Local staff should preferably be recruited
from the existing health system. However, in reality the lack of professional health workers
forces us to recruit among beneficiaries and host population.
If the psychosocial activity only involves a psychosocial referral component (see G.3, Figure 7)
then usually one or two (expatriate, national) mental health staff is sufficient.
96
J.3.9
Training
Training improves health workers ability to support beneficiaries. It is not the aim to create
certified mental health specialists or expert community workers.
Medical staff may need training about how to provide basic psychosocial support in medical
settings, and how to identify and refer people suffering from psychological problems.
Community workers and counsellors should be trained about community mobilisation, and
(mass) psycho-education.They should also receive extra, ongoing training on counselling skills.
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Specific objectives
Indicators
Output indicators:
Defined by the local population in terms of individual and group improvement in daily
functioning (e.g. improvement of social contacts, ancestors are resting in peace, decreased
worrying, improved physical activity, improved capacity for self-care, improved family
relationships, increased number of daily activities)
Process indicators:xxvi
Quantitative: increased appropriate cross referral (OPD component), increased number of
people seen in the counselling services, reduction of complaints/problems (psychocomponent), increased number of community activities (education or other), increased
number of people attending and number of people supported through community
outreach services (socio-component)
Qualitative: quality service, beneficiary satisfaction, perceived improvement of complaints,
beneficiary satisfaction (psycho-component), proximity to target population, connectedness
& quality of community network (socio-component)
Advocacy: human rights abuses or protection incidents, advocacy actions
Target population
Time perspective
6 months 3 years
Activities
Structure of
Services
Human Resources
Training
Strategy
Part of other medical intervention (e.g. basic health care,TB, nutrition, HIV/AIDS)
Strong community connection and involvement to increase efficacy
Balance psychoand socio components
Exit strategy and sustainability are secondary priorities (though attention must given)
xxvi If process-indicators (related to activities) are used, the assumptions need to be mentioned.
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J.4
J.4.1
Project purpose
Psychosocial care in most post-crisis settings aims to improve all peoples mental health (in the
broadest definition) instead of being limited to violence related complaints. Project purposes
encompass care, cure, protection and health system autonomy.
J.4.2
Specific objectives
Specific objectives for the project should be identified and developed by the beneficiaries or
their representatives.The specific objectives often include the specific aspects of the mental
health problems that need to be improved, support for capacity building, service design
(sometimes implementation) and technical guidance etc.
J.4.3
Indicators
Outcome and output indicators of success should be defined in terms of quality, efficiency,
effectiveness, participation, protection, autonomy and exit strategy.
J.4.4
Target group
The target group is all those in need of psychosocial support.
J.4.5
Time perspective
The intervention is aimed at sustainability and requires a long-term perspective.
J.4.6
Activities of care
Sometimes technical support is provided and capacity building facilitated in post-crisis situations.
However, the emergency-focused knowledge and limited time commitment of emergency
NGOs nearly always excludes them from these types of programmes.
Psychosocial care activities in post-crisis situations should integrate curative and preventive care
with health promotion.The provision of health care should be done in a holistic manner that
takes into account the physical, psychological and social dimensions of health and wellbeing.
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Activities of psychosocial and mental health services in basic health care include: symptom
relief, counselling, psychotherapy, and drug therapy; assistance for coping with the inevitable;
and preventing further deterioration through continuous health education.
Quality aspects of the relationship between beneficiaries and health care provider such as:
active beneficiary participation, supportive relationships, trust in the caregiver, maintenance of
beneficiarys autonomy and family ties, shared decision-making etc, are important aspects of the
activities.
Special activities related to destigmatisation or decriminalisation can be implemented when
relevant. In the case of human rights or protection issues of the mentally ill, activities must
include active monitoring of clients.
J.4.7
Structure of services
To increase the efficacy of prevention, decrease suffering (by early identification) and increase
self-help (by psycho-education), psychosocial care services need to be community-based.
Psycho-education is done through the established community health worker systems.
A basic organisation unit can cover approximately 10,000-15,000 people. Referrals should not
be limited to the health and community system, but include all structured government and
private initiatives.
A national mental health specialist should be responsible for clinically supervising services.
J.4.8
Human resources
Expatriates should provide hands-off advice and not be involved in any client relationship.They
should function only as specialists who give training and technical advice about clinical and
organisational issues. National professionals execute the psychosocial/mental health services, and
have long-term employment contracts.
J.4.9
Training
Training staff about clinical and organizational issues is one of the major activities.Training should
be in-depth to develop knowledge and skills that are important for the long term. Human and
client-rights training should be considered as an important subject for training.
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the major implementing partner.The Ministry of Health should make all decisions regarding
policy, resource allocation (by the overall budget) and priorities in setting norms for both change
and expected behaviour or attitude. Sustainability of services is very important and often the
exit strategy is a planned objective.The role of foreign support should be one of technical
assistance. Substitution can only be justified as an interim measure and on a temporary basis.
Tbl. 34 Summary of essential features of a psychosocial intervention in Post-Crisis/Rehabilitation
Psychosocial care in Post-Crisis/Rehabilitation
Project purpose
Specific objectives
Indicators
Outcome and output indicators should be defined in terms of quality, efficiency, effectiveness,
participation, autonomy and exit strategys
Target population
Time perspective
Long-term
Activities
Curative care
Psychosocial assistance
Preventive actions
Promotion of health as physical, social and mental well being
Destigmatisation
Lobbying, advocacy (optional)
Monitoring rights (optional)
Structure of
Services
Community-based
Budget from health system
Basic unit serves 10,000-15,000 people
Clinical supervision by national mental health specialist
Human Resources
Training
Strategy
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TRAINING
Training in a psychosocial project is an important tool but never a project goal in itself.Training
should be practical and focused on helping clients with psychosocial problems. Except for the
psychosocial skill training of the medical staff, it is never a stand-alone activity.There are serious
ethical problems around doing harm where national staff are exposed to knowledge and skills
without proper clinical back up for community workers or clinical supervision for counsellors.
Therefore, if community workers are trained, proper referral mechanisms (to trained medical
staff, clinically supervised local counsellors, or a mental health specialist) have to be ensured.
Training counsellors without daily clinical supervision of a mental health specialist (local or
expatriate) is potentially harmful for beneficiaries and for the staff themselves.
K.1
II. Attention to personal needs of participants: Almost all participants in the training will have
their own personal, traumatic experiences, for which they need some support.The training
is not only educational for participants, but also therapeutic. Education and therapy are
nicely combined during training through practice activities. Counselling techniques learned in
class can, for example, be put into practice by having participants counsel each other.
Participants thereby benefit doubly by learning about counselling and having their personal
suffering alleviated.The trainer must ensure a safe environment that protects participants
from re-traumatisation. When necessary the trainer can conduct individual consultations.
III. Sharing of Western knowledge and translation to local culture: Western insights can be
shared and, when accepted, translated for the local culture. It should be taken into account
that the participants need a concise, short-term and practice-oriented training without
professional jargon that is in line with their level of formal education.
K.2
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contact, intervene in crises and protect from further harm. The two or three days of training do
not aim to turn the medical staff into counsellors. In emergency situations the duration of the
training can be reduced.
K.3
K.3.1 Knowledge
Information about the programme and its services should be provided during its course. Specific
topics like stress, mood problems and other major issues such as suicide or substance abuse in
the community, as identified in the assessment, should be discussed. Local self-help mechanisms
such as peer support are explored and if relevant extended with other techniques. Issues like
confidentiality, advocacy and monitoring should also be addressed.
K.3.2 Skills and attitude
Practical issues like community mobilisation, planning and making health topic presentations and
organising distraction events should receive attention. Special attention should be given to the
design of education material such as leaflets and posters.
Working in the community confronts the workers with immediate problems that need
intervention.Therefore, support skills like active listening, compassionate attitude, knowledge of
how to deal with emotions, provide or mobilise social networks, crisis intervention, protect from
further harm, case identification and referral should be part of the training package.
K.3.3 Community exposure
Some exposure to problems in the community should be included in the training. Participants
can learn to compose a social map of (in)formal community resources, and to introduce
themselves and the programme to the community and its leaders.They can practice data
collection methods such as in-depth interviews and focus group discussions.
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K.4
Medical staff
(expatriate, national)
(2 or 3 days with follow-up,
given by expatriates)
Knowledge
Confidentiality
Psychological consequences of violence
How to explain (psycho-education)
What others should do about it (local coping mechanisms)
How to help yourself (self-help techniques)
Case identification, and
Referral options
Attitude and skills
Listening & communication
Dealing with emotions
Crisis intervention
Community workers
and counsellors
(2 weeks, given by
expatriates)
Knowledge
Programme and its services
Specific topics: stress, mood problems and other major issues
Self-help mechanisms
Confidentiality, advocacy and monitoring
Skills & Attitudes
Programme and self introduction
Listening & communication
Community mobilisation, planning & making health topic presentations or distraction events
Design of education material
Crisis intervention, relaxation, dealing with aggression and conflicts and case identification
Community exposure
Community problems, social map of community resources,
Self and programme introduction
Counsellors training
(2 weeks, given by external
trainer volunteers)
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K.5
Clinical supervision
Clinical supervision is a training method whereby counsellors examine a client case that causes
technical difficulties or triggers strong personal emotions. Clinical supervision is a contracted
activity; it is a shared reflection between the expatriate as clinical supervisor and the counsellor,
focusing on the counsellors client case.The goal is to give the counsellor guidance in the
delivery of cognitive and emotional care to his clients.163
Clinical supervision can be done individually or in groups. If regarded as an advanced way of
learning it has several purposes:
To encourage the learning process of counsellors through critical dialogue and reflection on
client cases.
To contribute to self-knowledge and self-understanding (personal growth) of the counsellors,
by encouraging them to reflect on their own feelings, thoughts and behaviour.
To explore personal problems and find new ways of dealing with them.
The work of the counsellors is sometimes very demanding..They need to give support to
traumatised clients while often being exposed to traumatic experiences themselves. Providing
the opportunity for clinical supervision can therefore contribute to the mental hygiene and
burnout management of the counselling staff.
For the expatriate mental health specialist working in non-Western settings clinical supervision
provides a good opportunity to stay tuned into the psychosocial problems and needs of
the community.
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L.1
Principles
It is difficult to measure and monitor the effectiveness of psychosocial programmes164 in
emergencies due to several factors:
Conventional monitoring and evaluation criteria are not applicable or valid in changing,
unpredictable and unstable contexts. Field reality challenges conventional evaluation criteria
such as determinants of effectiveness. Furthermore, documentation and systematic
measurement of outputs is often not possible in emergencies.
Epidemiological evaluation models advocated by Western psychiatry are insufficient to prove
the effectiveness of humanitarian actions.165 For example, evidence-based psychology and
medicine use effectiveness or impact as justification for psychosocial interventions, but
epidemiological data does not tell us anything about the fundamental motives for
humanitarianism: compassion, empathy and a sense of justice. Furthermore, most evidence is
based on Western situations and for higher technological interventions.
The cultural differences in the perception of trauma, expression of suffering, and the
mechanisms for coping makes it difficult to generalise from one context to the other.166
Culture-specific models and instruments to evaluate programme outputs improved resilience
require extensive time and resources (i.e. a long-term investment on behalf of MSF).
As a consequence, most projects depend on process indicators and qualitative research
outcomes to determine the effectiveness of their activities.
Since 1990, MSF and other organisations have progressively improved their evaluation models
and criteria for psychosocial interventions through evidence-based research,167 and evaluating
techniques.168
L.2
Acute emergencies
Acute emergency contexts change quickly.There is insufficient time to determine cross-culturally
validated outcome (impact) or output indicators. Process indicators (measuring activities) are
therefore used for programme planning and monitoring (see J.3). The relationship between
acute mental health interventions and positive treatment outcome is well established in other
settings. For instance, administering a psychotic client with anti-psychotic drugs is proven to be
effective in many settings.
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is monitored through clinical supervision and case discussions. General issues like humane
treatment, decent waiting areas, a sense of privacy, compassionate attitudes of health staff,
understanding of emotional suffering and confidentiality are observable process indicators in an
acute emergency.
L.2.3 Outreach
The main tasks of outreach services are to identify vulnerable individuals and refer them to
health or other services accordingly. In addition, outreach activities should provide information,
and basic assistance to people.
Tbl. 36 Overview of a monitoring system in acute emergency psychosocial care
Process Indicators
Source of Verification
Monitoring/Evaluation Tools
Number of stress-related
complaints and disorders in
OPD service
Psychosocial monitoringxxvii
Adequate intervention
Observation
Interviews
Regular supervision
Case discussions
Respectful treatment of
the individual
L.3
Chronic crises
Psychosocial projects in chronic crises combine emergency and development objectives,
activities and strategies. In principle, psychosocial projects in chronic crises need to develop
cultural-specific and locally defined outcome, or output indicators. Often, a standardised and
locally validated symptom or functioning checklist is not available.To create one, the local
population needs to be consulted and further research is required.This increases proximity and
allows for fine-tuning of the project to meet beneficiaries needs. A promising methodology is
described by Bolton.169
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context increases. Output indicators should be described both in qualitative and quantitative
terms. Output indicators should be described from a local individual and group perspective,
and include information about the following:
Local signs and symptoms of trauma related dysfunction and pathology
Local terms used to describe the improvement of psychosocial functioning or the reduction
of disability
Consequences of violence in terms of psychosocial functioning
Expected outcome of a psychosocial intervention
Examples of quantifiable positive outputs for traumatised people may include: reduction of
locally defined symptoms, ability to care for their family; increased number of meetings with
others; improved self-control over daily activities (e.g. self sufficiency in resources) and reduced
inter-relational conflict.These are just examples and need definition in local language. Surveys are
organised to measure knowledge improvement for instance on stress-related behaviour and
familiarity of psychosocial services as a result of social and educational activities.
The appreciation of services as qualitative output indicator is measured by means of
questionnaires.
L.3.2 Process indicators
Defining output indicators is time-consuming. Various reasons such as critical needs, lack of staff,
or insufficiently experienced staff, teams can stop the development of output indicators. Process
indicators are then used instead to describe the effectiveness of a programme. It must be
realised that process indicators only cover the activity level of the project. In other words the
decision to use process indicators limits future programme evaluation to the activities level.
Moreover, unlike in emergencies, the assumptions between the indicators and the effect on the
psychosocial condition of the client are less evident. For example, it is not certain whether
cognitive behavioural techniques that function in Western cultures have similar positive effects in
non-Western societies.
Process indicators are described both in qualitative and quantitative terms. Examples of
quantitative indicators are: number of stress related complaints or disorders, appropriate cross
referral to community and health services, number of people seen in counselling services and
the number of counselling sessions per counsellor. On the group level (socio-component),
indicators include a number of community activities (educational or otherwise), the number of
people attending, the number of people supported through community outreach services and
monitoring of human rights abuses or protection issues.
Qualitative indicators can further describe the extent to which activities affect the condition of
the client or community, and include: quality of services operationalised as sufficient client
contact time, file keeping, confidentiality, training and knowledge of counsellors, level of case
discussion etc.), improved restoration of human dignity, beneficiary satisfaction (psychocomponent), proximity to target population for instance presence in the community,
connectedness, quality of the community network like contacts with other NGOs, chiefs, leaders
and traditional healers (socio-component), and a specific indicator for advocacy action.
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Tbl. 37 Overview of a monitoring system for psychosocial care projects in chronic crises
Indicators
Output indicators:
Quantitative:
Psycho-component: If there are
no local culturally validated
symptoms of expression, then
local definitions of individual and
group improvement of
symptoms or functionality are
needed
Complaint reduction
Functionality improvement
Source of Verification
Monitoring/Evaluation Tools
FGD
Key informants
Workshops
Questionnaire
Socio-component: improved
Survey
knowledge about violence related
psychosocial problems, improved
knowledge about the services
Qualitative:
Service satisfaction
Process indicators:
Quantitative:
OPD component: number of
stress related complaints or
disorders, appropriate cross
referral
Psycho-component: number of
people seen in the counselling
services, number of counselling
session per counsellor
Exit interviewsxxviii
Drop-out analysisxxix
Satisfaction checklist
OPD Medical
Monitoring
Exit-interview
Psychosocial monitoring
Exit-interview
Drop-out analysis
Socio-component:
Psychosocial monitoring
number of educational
Monthly reports
community activities (education
or other), number of people
attending and number of people
supported through community
outreach services, community
networking, number of referrals
Qualitative:
beneficiary satisfaction, quality of
counselling (psycho-component),
proximity to target population,
connectedness & quality of
community network (sociocomponent)
Advocacy
Questionnaire
Key informant
FGD among
beneficiaries
Observations
Survey
Exit interviews
Drop-out analysis
Advocacy strategy
Reports
Observations
xxviii Exit interview: clients leaving the counselling session are interviewed on certain topics (e.g. satisfaction with services, improvement of complaints,
increased functioning etc.)
xxix Drop-out analysis: A random selected number of people of the group who did not follow-up on their appointments are interviewed about their
reasons for dropping-out, current level of symptoms, complaints, etc.
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M.1
M.2
Expatriate
Professional background (e.g. psychiatrist, psychotherapist, clinical & counselling psychologist, social
worker, social psychiatric nurse)
Work experience (clinical, community-based)
Attitudes/expectations towards humanitarian work
National
Professional background
Attitudes and compassion
Interpersonal skills
Level of interest and motivation for the work
Previous counselling experience and training
Ability to analyse, plan and intervene when faced with difficult or complex cases (tested through the use
of three short case studies)
Job descriptions
The job descriptions of all psychosocial workers (mental health expatriate, counsellors and
community health workers) must contain an explicit statement about the obligation to respect
the confidentiality of the counselling relationship.
In the job description of expatriates or national staff it seems logical to divide tasks along the
lines of the psychoand the socio-components of the programme. However, this may result
in a distinct separation between the two activities. Clinical people should not feel responsible
only for the psycho-component and community people only for the socio-component.
Such separation can seriously reduce the success of the project.To avoid this problem it is
advised to combine clinical and community components in the job descriptions of the mental
health expatriate and the counsellors.
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M.3
Staff support
Members of national staff (including management, translators and drivers) are often traumatised
themselves. Additional daily confrontation with clients problems, traumatic stories, sadness and
loss are demanding and potentially draining.This is especially the case when faced with clients
who have little chance of significant improvement, for instance the terminally ill or AIDS clients.
Therefore, the risk of professional burnout is high among national staff. Signs of burnout are
described in Table 39.
Physical
Behaviour
Difficulty in concentrating
Frequent bad moods
Feelings of anxiety or
generalised fear
Constant tiredness
Undiagnosed physical
complaints
Hyperventilation
Each project must have a burnout prevention policy and its own Helping the Helpers system
for national staff. Burnout management is essential and mainly focuses on prevention. It involves:
Task management: job rotation of psycho and socio tasks, and case diversification;
Professional growth: clinical supervision, and on-going training;
Team management: team work, regular team meetings, regular social events, planned holidays,
and regular pay;
Psychological support when required: a structure of peer support, and a formalised Helping
the Helpers system.
Someone, preferably outside the organisation should provide psychological support to the
national staff. However, when this is not possible the expatriate mental health worker should
provide psychological care.
Expatriate staff have access to two forms of care.Team members can give social and technical
support. Specific technical advice is available from the medical line manager and technical
advisors from the headquarters. If the mental health expatriate needs personal support the care
can be provided by the organisations psychosocial care unit.
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Staff support
Content
National staff
Helping the Helpers
Peer Support
Psychological support (preferably external)
Expatriate
Team work
Technical support
Psychosocial Care Unit (Headquarters)
LOGISTICS
Medical as well as mental health projects depend heavily on logistics.Transport, communication
and security management are of vital importance, especially in projects serving a large
beneficiary population.
The creation of a silent space for counselling is another area in which logistics becomes involved
in psychosocial programmes. Understanding what people with psychosocial problems need (e.g.
confidentiality, privacy, quiet rooms) is essential.The counselling space should preferably be
located within the medical facilities.
In emergency contexts special attention should be given to the severely ill. Both a resting area
(day care) and special waiting area for clients is necessary.
Lastly, logistics are needed to organise community activities, distraction or education activities.
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DEFINITIONS
Anthropological tools can be used to gather detailed information about beneficiaries perspectives
on mental disorder (e.g. causation and symptomology), local health management strategies for instance
religious healing, herbalism and witchcraft, and expected outcomes of psychosocial interventions.
Avoidance is a common reaction following a traumatic experience whereby an individual forgets,
ignores, denies information or painful recollections about the traumatic event. Avoidance is generally
a temporary response and a normal part of the coping process. If it becomes a habitual reaction or
permanent state, avoidance can impede both the coping process and healing.
Anxiety disorder is a generalised term that refers to a group of psychological disorders characterized
by excessive tension and worry. Anxiety disorders may be linked to specific situations or involve general
states, definable by the DSM-IV.171
Burnout is a combination of tiredness, tagycardia, nausea, high blood pressure and psychological
complaints such as restlesness, sleep disturbances and emotional exhaustion. It is the result of a long
process that eventual ends in total collapse of the person.
Beneficiary refers to a member of the target population that is receiving humanitarian medical
assistance within a specified intervention area; the term is used when discussing management aspects
of a programme.
Client refers to a beneficiary who has been admitted into a mental health or psychosocial programme
to receive care, and is involved in a therapeutic relationship with a counsellor/mental health practitioner.
The client is not called patient (as in the medical setting) because psychosocial or mental health support
is not necessarily restricted to medical disorders.
Clinical supervision is a contracted activity; it is a shared reflection on a client case between the
clinical supervisor, often the expatriate, and the counsellor (also referred to as the supervisee).The focus
of reflection is on the supervisees work in order to give the supervisee more cognitive, more emotional
and more independent perspective on his clients case.172
Cognitive-behavioural oriented brief-therapy See Cognitive Behaviour Therapy. Brief refers to
a limited number of sessions (6 to maximum 12).
Cognitive Behaviour Therapy is an action-oriented form of psychotherapy that assumes that
maladaptive, or faulty, thinking patterns cause counter-productive behaviour and negative emotions.
Treatment focuses on changing an individual's thoughts (cognitive patterns) in order to modify his
behaviour and emotional state, and involves a collaborative effort between counsellor and client.
Clients are taught to view automatic thoughts (maladaptive cognitions) as hypotheses subject to
empirical validation, rather than as established facts.Therapy gives clients an active role in their healing
process and empowers them by providing them with skills and experiences that create adaptive thinking.173
Cognitive Behaviour Therapy is typically administered in an outpatient setting in either an individual or
group session. It is currently popular because of the relatively low number of treatment sessions and its
positive scientific effectiveness evaluation.
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Comprehensive health care approach assumes a holistic interpretation of the human being as
being physical, mental, social, spiritual and moral in nature. Definitions of health and disease are
understood not only in terms of traditional categories of physical and mental physiology, but also in
term of socio-cultural and religious worldviews.
Coping is a process in which the individual (or group) deals with situations by managing them
adequately without necessarily mastering them completely.174 After a traumatic experience, new
information needs to be processed, assimilated and integrated into a new worldview. According to
cognitive processing theories the two most common elements of the coping processes are intrusion
and avoidance.175
Counselling is a relationship in which a helper assists a client to understand himself and his problems
better. Where appropriate, the helper uses various strategies to clarify and expand the clients
understanding, to assist him to develop and implement strategies for changing how he thinks, acts,
feels so he can attain life-affirming goals.176
Counter-transference. See below for a definition of transference.
Cultural psychology is the study of the ways in which subject and object, self and other, psyche
and culture, person and context, figure and ground, practitioner and practice live together, require
each other, and dynamically, dialectically, and jointly make each other up. Psychological differences
are understood by virtue of the ways in which socio-cultural environments shape and affect
peoples responses.
Depression in moderate manifestations is a condition characterized by negative feelings about the self,
pessimism about the future, a general sense of inadequacy and a slowed activity rate. More extreme
forms involve withdrawal into the self, possible development of the sense of hopelessness and perhaps
delusions of guilt and inadequacy.Transcultural psychiatry emphasizes that local definitions of self affect
a clients experience of depression,xxx and how he expresses emotions and symptoms. Causes and
symptoms of depression therefore differ according to cultural context and behavioural norms.
Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard international
diagnostic classification system and coding reference for mental disorders. It contains categories, criteria,
and descriptions designed to assist the process of diagnosing individuals with mental disorders.The DSM
is intended for use by individuals who have appropriate clinical training.177
Diaries are qualitative tools used to validate information such as about the prevalence of symptoms,
reduction of social contacts from interviews.
Disassociation is a psychological coping mechanism that involves the disruption of cognitive functions
that are usually integrated, such as consciousness, memory, identity, or perception of the environment.
Disease refers to the way practitioners recast illness in terms of their theoretical models of pathology.178
Drop-out analysis involves the random selection of a number of people who previously received
counselling support, but who did not return follow-up appointments; this is followed by an interview
about their reasons for drop-out, current level of symptoms and complaints.
xxx The transcultural psychiatry concept self differs from the traditional Freudian one. It sees the self as culture-dependent (i.e. not a static ego) and
is constantly evolving parallel to changes in its socio-cultural environment.
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115
behaviour, accepted and unaccepted emotions or cognitions by a group of people. Mass violence can
have serious effects on these individual and group values.They can affect peoples judgments, shatter
beliefs about trust and the benevolence of the people and destroy community norms of generally
acceptable behaviour, emotions and cognitions. Definitions of what is morally good or bad, and
therefore healthy or unhealthy, are culture-specific, and defined by local systems.
Outcome indicators measure, in relation to a stated project purpose, the results of the combined
project activities including those of others.183
Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur if people are
unable to integrate their traumatic experience in their present life. PTSD is marked by clear biological
changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in
conjunction with related disorders such as depression, substance abuse, problems of memory and
cognition, and other problems of physical and mental health. PTSD can be diagnosed three months
from the traumatic incident. Before this most of the problems are regarded as part of the normal
coping process.
Problem-focused coping is a style of coping in which a person or group focuses all energy and
resources to solve the stress-creating problem. It is a practical approach, and the opposite of emotionfocused coping.
Process indicators measure the extent to which activities have been undertaken designed to achieve
a stated specific objective.
Psychological anthropology focuses on behaviour (performance) such as rituals, folk tales, games
and art, kinship or religions etc., and has as its underlying assumption that all humans have an inherent
central processing mechanism, or a deep processing system (psychic unity).
Psychological package is the part of a psychosocial programme that focuses directly or indirectly
through the training of health staff on the problems of behaviour or personal emotions (e.g. fear,
despair), and thoughts.
Psychology assumes that humans have a central procession mechanism that is transcendent, abstract,
fixed and a universal property of the human psyche. It does not believe in a context-free, meaning-free
stimulus of thought and or action. It seeks to differentiate (isolate) central processing functions and
development of the mind (e.g. discrimination, categorisation, memory, emotions, behaviour learning,
motivation, inference, etc.).184
Psychosis is a mental disorder sufficiently severe to result in personality disorganisation and a loss of
contact with reality.
Psychosocial health indicates the presence of life or personal problems that undermine daily normal
functioning.The definition of what constitutes normal varies cross-culturally and between individuals.
Psychosocial illnesses are conditions of not well being, common in the community.The relationship
between psychological and social effects is dynamic, mutual and ongoing. Psycho refers to psychological,
that means problems of behaviour or needs of personal emotions, thoughts and feelings like fear and
despair. Social refers to the interaction between the individual and a larger group such as family,
community and/or its environment (physical, moral, spiritual).That means, for instance, problems or
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needs that are related to displacement, refuge, suppression, poverty, domestic violence, marital problems,
child abuse etc. Social problems can easily affect the psychological status of the individual. Psychological
problems can affect the individuals social (e.g. interpersonal relations) well being.185
Psychosocial questionnaires are structured interviews used for the large-scale appraisal of
psychosocial needs in closed (camp) and open (community) settings.They provide insight into the
events through exposure or witnessing, the psychological impact (the standardised impact of event scale
IES), the prevalence of specific health complaints and stress (General Health Questionnaire 28, GHQ
28) and some questions on knowledge, attitude, and self-help mechanisms.186
Qualitative assessment instruments provide subjective data about individuals or groups in a
beneficiary population, and include the following: literature reviews, focus group discussions, key
informant interviews, structured or checklist observation, diaries, mapping, anthropological tools,
workshops and dictionaries.
Quantitative assessment instruments provide objective data about individuals/groups in a
beneficiary population, and include the following: basic health care data and mental health statistics,
psychosocial questionnaires, symptom checklists, and self-completion questionnaires.
Rape includes any sexual act or penetration, of any kind whatsoever, committed on another person by
means of violence, compulsion, threat or surprise. Rape is commonly used as a weapon of war in
conflict settings.187
Resilience is the capacity to restore a new balance when the old ones are challenged or dysfunctional.
Resilience is defined through physical, mental, social, spiritual and moral systems.The popular translation
of resilience: the ability to bounce back, is inadequate because after traumatic experiences a new
balance (or worldview) needs to be established, rather than old ones restored.
Self-completion questionnaires are quantitative instruments containing short open-ended
questions used to obtain quick information about sensitive subjects.
Social health involves the ability to engage in social interaction and/or be an active member of a
community.The ability to mobilise appropriate social support is equally important to having a social
network. Both are measures for social health.
Social package is the part of the psychosocial programme that focuses on the provision of practical
support, community education, mobilisation and stimulation activities, the aim of which is to enhance the
mutual interaction between the individual and a larger group such as family and community or his
environment (physical, moral, spiritual).
Somatisation involves the translation of emotions such as distress or sadness into physical signs and
symptoms. Somatic symptoms serve as cultural idioms of stress in many ethnocultural groups and, if
misinterpreted by the mental health specialist, counsellor or medical professional, may lead to
unnecessary diagnostic procedures or inappropriate treatment.188
Spiritual health. Spirituality has been defined in various ways, ranging from a New Age understanding189
of spirituality to the criteria defined by the Spiritual Experience Index.190 The term spirituality was
preferred to the term religion because it describes a wider range of religious experiences outside
117
organised groups. Nevertheless, spirituality and religion are inseparable because spirituality is an essential
element of religious life.191
Spirituality presupposes the existence and experience of spirit, something ego-transcendental; something
we may call divine power. Spirituality can be defined as the ability of the human mind to relate to
transcendental power.192
Traumatic experiences can lead to a major shift in the individuals internal belief systems, either as
powerful sources of motivation or destruction. Spiritual health goes beyond religious affiliation and the
belief in God. It is a state of inspiration, reverence, awe, meaning and fulfilled purpose; a state of
harmony with the universe and questions about the infinite. Spiritual health or disorder becomes
noticeable in times of emotional stress, physical (and mental) illness, loss, bereavement and death.193
Performing rituals (especially burial) and visiting places of contemplation or worship are powerful tools
to promote spiritual health.
Stressful events and traumatic stress have not been distinguished successfully yet.The
qualification of an event being traumatic or stressful is bound individually. Events that do not involve
extreme stress (immediate survival) can be perceived as challenging by some or as threatening by
others.Traumatic stress is often associated with wars, captivity, torture, disasters and racial
discrimination.194
Structured or checklist observation is a qualitative tool for rapidly acquiring information about
beneficiaries and includes: direct observation, walking around and clinical observation. This tool is a
good method to see whether people actually do what they say in interviews.
Stupor is defined as mutism and akinesis: a client appears alert because of eye movements, but is
unable to initiate speech or action. Consciousness is clouded and attention for environmental stimuli
is diminished. Anxiety and neurological symptoms are absent; respiration, pulse and blood pressure
are stable.
Supplementary Feeding Programme (SFP) provides nutritional support (in the form of daily
wet rations or weekly dry rations) to moderately malnourished individuals.
Symptom checklists (HSCL 25, IES, GHQ 28) are quantitative instruments used to assess the
prevalence of psychosocial stress symptoms in a population. Symptom checklists are in general not
validated for non-Western cultural environments.195
Therapeutic Feeding Programme (TFP) provides intensive medical and nutritional support to
severely malnourished individuals.Treatment is given under clinical supervision over a two-week period.
The Stress Model is used to explain how social environment influences personality development and
the origin of mental and other disorders. Serious perturbations, or stressors, disturb an individuals
psychological equilibrium and cause him/her to initiate coping activities to restore their mental health.
Mental disorders and distress may arise from the interaction between the stressor (e.g. a life changing
event) and the individual who perceives the event as stressful, threatening, or uncontrollable, and
worsen in the absence of adequate social support and other coping responses.196
Traditional medicines are those diverse health practices, approaches, knowledge and beliefs
incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual technologies and
exercises applied singularly or in combination to maintain the well-being of the client, as well as to treat,
118
119
Human rights
Amnesty International
www.amnesty.org
Human Rights Watch
www.hrw.org
International Societies, NGOs and Associations
Alertnet
www.alertnet.org
American Psychology Association
www.apa.org
Colegio Oficial de Psiclogos (Espaa)
www.cop.es/cop
Center for International Disaster Information (CIDI)
www.cidi.org
ERCOMER - The European Research Centre on Migration and Ethnic Relations
www.ercomer.org
Geneva Initiative for Psychiatry
www.geneva-initiative.org
Interaction
www.interaction.org
International Association for Cross Cultural Psychology
www.iaccp.org
International Centre for Migration and Health (ICMH)
www.icmh.ch
International Society for Traumatic Stress Studies
www.istss.org
Pan American Health Organisation
www.paho.org
Red Cross and Red Crescent Movement
www.icrc.org
Refugee Studies Centre
www.rsc.ox.ac.uk
Relief Web (UN website providing information to humanitarian relief organisations)
www.reliefweb.int
120
Sphere Project
www.sphereproject.org
UN SYSTEM
United Nations
www.unsystem.org
UNAIDS
www.unaids.org
United Nations Children's Fund
www.unicef.org
United Nations High Commissioner for Refugees
www.unhcr.ch
United Nations Development Fund for Women
www.unifem.org
United Nations Development Programme
www.undp.org
United Nations Population Fund
www.unfpa.org
OCHA IRIN
www.irinnews.org
WHO
World Health Organisation
www.who.int/en
www.who.int/mental_health/media/en/investing_mnh.pdf
www.cvdinfobase.ca/mh-atlas (maps, tables and charts including country profiles on mental health)
World Organisation Against Torture
www.derechos.org/omct
World Association for Psychosocial Rehabilitation (WAPR)
www.candido.org.br
World Federation For Mental Health Homepage
www.wfmh.com
121
122
123
Journals
American Psychological Society
www.psychologicalscience.org/journals
British Medical Journal www.bmi British Medical Journal
bmj.bmjjournals.com
International Journal of Psychosocial Rehabilitation
www.psvchosocial.com
Journal of American Medical Assocition (JAMA)
jama.ama-assn.org
NEJM
content.nejm.org
Psychiatric Rehabilitation Journal
www.bu.edu/pri/
Grey Literature
Humanitarian Information Network (HIN)
www.reliefweb.int
www.reliefweb.int/hin/lib.htm
Psychosocial working group
www.forcedmigration.org/psychosocial/
Special topics
Caring for Carers
Caring for Carers. UNAIDS, 2000
www.unaids.org
Physician Stress and Burnout. TMA, 2003
www.texmed.org/cme/phn/psb/burnout.asp
Community education
Manual for Health Communication. Centre for Health Promotion,
University of Toronto, March, 2002
www.thcu.ca
124
HIV/AIDS
VCT The impact of Voluntary Counselling and Testing. A global review of the
benefits and challenges. UNAIDS, 2001
www.emro.who.int/asd/backgrounddocuments/egy0703/ImpactVCT.pdf
CDC
www.cdc.gov/mmwr/preview/mmwrhtml/mm5146a5.htm
Voluntary Counselling and Testing (VCT). UNAIDS Technical Update, May 2000
www.emro.who.int/asd/backgrounddocuments/egy0703/VCTTechnicalUpdate.pdf
Psychotropic drug and ARV interaction
www.medsape.com
Sexual Violence
Sexual violence guidelines
www.rhrc.org
Torture
Examining Asylum Seekers
www.phrusa.org/campaigns/asylum_network/manual.html
125
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